Fillable Printable Disabled Parking Application For Individuals

Disabled Parking Application For Individuals

Disabled Parking Application for Individuals

Once you and your healthcare provider have completed the appropriate sections, take this application AND signed

authorization from your healthcare provider to any vehicle licensing ofﬁce or mail to: Special Plate Unit,

Department of Licensing, PO Box 9043, Olympia, WA 98507.

Applicant

PRINT or TYPE Name (Last, First, Middle initial) Date of birth (mm/dd/yyyy) Gender

Male Female

Mailing address (PO Box or street address and apartment number, if applicable) City State ZIP code

(Area code) Daytime phone Email Current license plate, if applicable Registration expiration, if applicable

Applicant or authorized representative signature

Parking privilege options

Your healthcare provider will determine if you get temporary or permanent disabled parking.

• Temporary placard – valid for 1 year or less. Only one placard will be issued (no fee required). A new application is

required to renew.

• Permanent disabled parking – valid for 5 years. You must be the registered owner of the vehicle that has permanent

plates or tabs. Before your privilege expires, we will send you a renewal notice.

Permanent disabled parking choices (choose only one)

Placard only – no fee required

Number of placards: 1 2

Permanent plates – fee required (see dol.wa.gov for current fees)

Select one: 1 placard and 1 set of license plates 1 set of license plates

Disabled parking tab for specialty or personalized plates – fee required (see dol.wa.gov for current fees)

Select one: 1 disabled parking tab 1 placard and 1 disabled parking tab

Disabled parking tab for WATV – fee required (see dol.wa.gov for current fees)

Select one: 1 disabled parking tab 1 placard and 1 disabled parking tab

You will receive an identiﬁcation (ID) card 2 to 4 weeks after we process your application. Keep it with you to show law

enforcement, if asked.

Healthcare provider

You must provide a signed authorization stating: (1) the applicant’s name and (2) they have a condition which qualiﬁes them

for disabled parking privileges. This authorization must be on prescription paper or your ofﬁce letterhead. If this application is

printed on prescription paper, it meets both the application and authorization requirements. Return this form and your signed

authorization to the applicant.

PRINT or TYPE Name Professional classiﬁcation Professional license number

Ofﬁce address (Street address, City, State, ZIP code) (Area code) phone number

Privilege duration

Permanent Temporary for: months (up to 12 months)

Answer the following

My patient meets one of the following qualifying conditions:

•Cannot walk 200 feet without stopping to rest

or must use assistive device

•Walking severely limited due to arthritic, neurological,

or orthopedic condition

•Uses portable oxygen or walking restricted by lung disease

•Class III or IV impairment by cardiovascular disease

•Acute sensitivity to auto emissions that limits ability to walk

•Legally blind with limited mobility

•Restricted by porphyria (applicant beneﬁts from a decrease

in exposure to light)

I certify under penalty of perjury under the laws of the state of Washington that the applicant named above has a medical

necessity that severely affects mobility or involves acute sensitivity to light.

Date and place (city or county) signed MD, DO, DC, DPM, ND, ARNP, or PA ONLY signature

A parking permit for a person with disabilities may be issued only for a medical necessity that severely affects mobility or involves acute

sensitivity to light (RCW 46.19.010). An applicant or healthcare practitioner who knowingly provides false information on this application

is guilty of a gross misdemeanor. The penalty is up to 364 days in jail and a ﬁne of up to $5,000 or both. In addition, the healthcare

practitioner may be subject to sanctions under chapter 18.130 RCW, the Uniform Disciplinary Act.

RCW 46.19 WAC 308-96B-010

TD-420-073 (R/9/17)WA

Click here to START or CLEAR, then hit the TAB button

Complete this section and print; applicant or authorized representative signs here

Physician signs here.