AUTHORIZED SIGNATURE (Must be physician, certified registered nurse practitioner or certified nurse midwife signature) DATE
PRINTED NAME MEDICAL LICENSE NUMBER (IF APPLICABLE) TELEPHONE NUMBER
OFFICE ADDRESS CITY STATE ZIP
AlAbAmA DepArtment of revenue
m
otor vehicle Division
www.revenue.alabama.gov
Application for Disability Access parking credentials
MVR 32-6-230
12/21
APPLICANT NAME COUNTY TELEPHONE NUMBER
PHYSICAL ADDRESS MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL)
CITY STATE ZIP
DRIVERʼS LICENSE (OR NON-DRIVER ID) ISSUING STATE EXPIRATION DATE (MONTH/YEAR) EMAIL ADDRESS
FEDERAL EMPLOYER IDENTIFICATION NUMBER (ORGANIZATION ONLY)
Applicant certifies, under penalty of perjury, that the applicant meets the requirements necessary to receive disability access parking credentials.
APPLICANT SIGNATURE DATE
Individual
Parent, Stepparent, or Legal Guardian of an individual with a Disability
Organization
( )
An individual with qualified disabilities must obtain certification from a licensed physician, certified registered nurse practitioner, or certified nurse
midwife prior to the initial issuance of disability access credentials. An individual with permanent disabilities may self-certify their qualifying disability
if they are renewing their disability access credentials. A separate certification is not required to obtain replacement disability access credentials.
APPLICANT INFORMATION
An individual with disabilities which limits or impairs their ability to walk means (check all that apply):
Cannot walk two hundred feet without stopping to rest;
Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device;
Are restricted by lung disease to such an extent that the personʼs forced (respiratory) expiratory volume for one second, when measured by spirometry, is
less than one liter, or the arterial oxygen tension is less than 60 mm.hg on room air at rest;
Use portable oxygen;
Have a cardiac condition to the extent that the personʼs functional limitations are classified in severity as Class III or Class IV according to standards set by
the American Heart Association;
Are severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.
Please check below the length of disability:
Permanent Disability.
Temporary Disability (period not to exceed six months). Beginning Date: ______________________ Ending Date: _______________________
The undersigned affirms under penalty of perjury that the applicant has the specific disability(ies):
REQUIREMENTS AND CERTIFICATION
( )
Return this application to your local licensing office
CITY STATE ZIP
Disability Access parking credentials may be issued to an individual with a disability or a parent, stepparent, or legal guardian of an individual with a disability.
Applicants with permanent disabilities are eligible for two (2) disability placards per person OR one (1) placard per person AND one (1) license plate decal per
vehicle. There is no fee for placards or decals. Organizations that transport individuals with disabilities are eligible to apply for a Disability Access license plate
decal.
/
CREDENTIALS BEING REQUESTED:
DISABILITY ACCESS LICENSE PLATE DECAL: (Permanent Disability only)
DISABILITY ACCESS PLACARD(S)
APPLICATION TYPE:
NEW
RENEWAL
REPLACEMENT
OFFICIAL USE ONLY
PLACARD AND/OR LICENSE
PLATE NUMBER ASSIGNED
_______________
_______________
Lost
Stolen
Mutilated
Please select reason for replacement below:
