State of 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) APPLICATION CHECKLIST: APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARDS FOR PERSONS WITH DISABILITIES PLEASE USE THIS CHECKLIST BEFORE MAILING YOUR APPLICATION TO MAKE SURE THAT IT IS COMPLETED FULLY, ACCURATELY AND LEGIBLY AND THAT ALL THE REQUIRED DOCUMENTS ARE INCLUDED. IF NOT, THE APPLICATION MAY HAVE TO BE RETURNED TO YOU FOR RE-SUBMISSION WHICH WILL CAUSE DELAYS IN RECEIVING YOUR PLATES AND/OR PLACARD. Section A: General Information Name and address of Applicant is provided and legible Applicant is a New Jersey resident Either Applicant’s Driver License Number OR DOB, Sex, Eyes, Height and Weight are indicated and legible It is clearly indicated (box is checked) that Applicant is applying for license plates and/or placard Section A: If you are applying for Handicapped Symbol License Plates All information is provided and legible Vehicle Owner signed and dated application Relationship of vehicle owner to person with disability is clearly indicated (box is checked) Applicant signed and dated application A copy of current, valid Vehicle Registration is provided Vehicle is not registered to a company, organization or group Section A: If you are applying for a Placard “New” or “Replacement” is clearly indicated (box is checked) If replacement placard, indicate previous placard number if known If replacement placard, attach notarized statement attesting that both original placard and identication card were lost Applicant signed and dated application Section B: Physician’s Certification The appropriate box (es) (Items 1-6) are checked indicating applicant’s qualifying disability Applicant’s name and box number is provided and legible in certification statement Please Note: The number of the qualifying medical condition must be checked and further identified in the certification (written in). Physician signed and dated application All Physician information is provided and legible REV 6/08 1 American LegalNet, Inc. www.FormsWorkFlow.com