New Jersey Motor Vehicle Commission Special Plate Unit PO Box 015 Trenton, NJ 08666-0015 (888) 486-3339 (NJ toll-free) (609) 292-6500 (Out of state) I.D. Card No: ________________ License Plate No: __________________ Placard No: ________________ Date Issued: ________________ (FOR COMMISSION USE ONLY: DO NOT WRITE ABOVE THIS LINE) APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARDS FOR PERSONS WITH DISABILITIES (PAGE 1 OF 2) SECTION A: APPLICANT INFORMATION THE APPLICANT MUST COMPLETE THIS SECTION BEFORE PHYSICIAN’S CERTIFICATION (SECTION B). TO AVOID DELAYS IN PROCESSING PLEASE READ ALL INSTRUCTIONS CAREFULLY, TYPE OR LEGIBLY PRINT ALL ENTRIES, AND VISIT ANY LOCAL MOTOR VEHICLE AGENCY WITH THE COMPLETED APPLICATION. Name of Applicant: __________________________________________________________________________________________ Street Address: ______________________________________________________________________________________________ NJ RESIDENTS ONLY City, State, Zip Code: _________________________________________________________________________________________ NJ RESIDENTS ONLY Applicant’s Driver License Number: ___________________________________________________ OR If Applicant does not have a current NJ Drivers License, please provide: Date of Birth: _________ Sex: ______ Eye Color: ______ Ht: _______ Wt: ________ I AM APPLYING FOR: LICENSE PLATES PLACARD (Complete Applicable Section Below) Please Note: License plates and/or placards for eligible persons are issued with an Identification Card and are to be used exclusively for and by the person named on the Identification Card. LICENSE PLATES: COMPLETE THIS SECTION IF APPLYING FOR LICENSE PLATES/ IDENTIFICATION CARD. WHEELCHAIR SYMBOL LICENSE PLATES MAY BE ISSUED FOR ONE VEHICLE OWNED, OPERATED OR LEASED BY A PERSON WITH DISABILITIES OR FAMILY MEMBER PROVIDING TRANSPORTATION FOR THAT PERSON. COMPLETE BELOW AND SEND A PHOTCOPY OF THE VEHICLE REGISTRATION: Registered Owner of Vehicle________________________________ Current Plate No._____________________ Expires______________ Owners Driver License No._____________________________________________________________________________ Street Address________________________________________ City, State, Zip Code_____________________________ Relationship to the person with the disability: Self Parent Guardian Other ________________________ (Please Specify) The license plates are to be used exclusively for the person named on the identification card. The identification card is nontransferable and will be forfeited if used by any other person. Abuse of this privilege is cause for revocation of both the license plates and identification card and possible criminal sanctions. I CERTIFY, UNDER PENALTY OF LAW, THAT THE STATEMENTS ON THIS APPLICATION ARE TRUE. Registered Owner’s Signature: _________________________________________________________________________ Applicant’s Signature: ______________________________________________________________ Date: ___________ PLACARD: COMPLETE THIS SECTON IF APPLYING FOR A PLACARD/ IDENTIFICATION CARD NEW REPLACEMENT (OLD PLACARD # ________________ IF KNOWN. TO REPLACE PLACARD AND ID CARD, ATTACH NOTARIZED STATEMENT ATTESTING THAT BOTH ORIGINAL PLACARD AND ID CARD WERE LOST.) The placard must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a designated handicapped symbol parking space and must be removed when the vehicle is in motion. The placard is for the exclusive use of the person named on the identification card. The identification card is non-transferable and will be forfeited if used by any other person. Abuse of this privilege is cause for revocation of the both the placard and identification card and possible criminal sanctions. The placard expires in three (3) years and must be renewed and that upon receipt of the renewal application, under law, the Motor Vehicle Commission may request recertifying qualifications from a physician. I CERTIFY, UNDER PENALTY OF LAW, THAT THE STATEMENTS ON THIS APPLICATION ARE TRUE. Applicant’s Signature: _____________________________________________________________ Date: ___________ American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARDS FOR PERSONS WITH DISABILITIES (PAGE 2 OF 2) I.D. Card No: ________________ License Plate No: __________________ Placard No: ________________ Date Issued: ________________ (FOR COMMISSION USE ONLY: DO NOT WRITE ABOVE THIS LINE) Applicant Name (print)_______________________________________________________________________________________ SECTION B: PHYSICIAN’S CERTIFICATION THE FOLLOWING MUST BE COMPLETED AND CERTIFIED BY A MEDICAL DOCTOR, PODIATRIST OR CHIROPRACTOR WHO IS LICENSED TO PRACTICE IN NEW JERSEY (OR A BORDERING STATE): By law, eligibility for license plates and/or placards for persons with disabilities is limited to the following conditions. (NO OTHER PERSON IS ELIGIBLE FOR LICENSE PLATES OR PLACARDS). Please check the most appropriate box/boxes. The applicant: 1. Has lost the use of one or more limbs as a consequence of paralysis, amputation, or other permanent disability 2. Is severely and permanently disabled and cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assistive device. 3. Suffers from lung disease to such an extent that the applicant’s forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixth mm/hg on room air at rest; or uses portable oxygen. 4. Has a cardiac condition of the extent that the applicant’s functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association. 5. Is severely and permanently limited in the ability to walk because of an arthritic, neurological, or orthopedic condition; or cannot walk two hundred feet without stopping to rest. 6. Has a permanent sight impairment of both eyes as certified by the N.J. Commission of the Blind (Placard only). Under New Jersey law (N.J.S.A. 2C:21-4a), making a false statement or providing misinformation on an application to obtain or facilitate the receipt of license plates or placards for persons with disabilities is a fourth degree crime and a person who has been convicted of this offense may be subject to pay a fine not to exceed $10,000 and a term of imprisonment of up to 18 months. I certify and attest, under penalty of law, that _______________________________________ has appeared before me and (Print Applicant’s Name) meets the eligibility criteria as specified in box number(s) ______ (checked above) and thus meets the requirements for the receipt of license plates and/or placards for persons with disabilities. Signature of Physician __________________________________________________ Date______________ PLEASE TYPE OR PRINT: PHYSICIAN NAME, LICENSE NUMBER, ADDRESS AND TELEPHONE NUMBER ___________________________________________________________ (Physician’s Name) ___________________________________________________________ (License Number/State) ___________________________________________________________ (Street Address) ___________________________________________________________ (City, State and Zip) _____________________________ (Date) ______________________________ (Telephone Number) (Please Note: If the above information is not clearly legible it may result in delays in applicant receiving plates and/or placard). ____________________________________________________ IMPORTANT NOTICE Plates must be renewed every year and placards must be renewed every three years. Upon receipt of an application for renewal the Motor Vehicle Commission may require the applicant to submit a statement from a physician recertifying his/her qualification as provided under N.J.A.C. 13:20-9.1(a) 4. SP-41 (R3/09) American LegalNet, Inc. www.FormsWorkFlow.com