Persons With Disability Parking Place Application First Name First Middle Last Address Street Address PhoneCERTIFICATION FROM PA LICENSED PHYSICIAN – MUST BE COMPLETELY IN FULL. This is to certify that the person who with the disability listed above is under my care and has the following condition listed at the bottom of the form is under “Eligibility Requirements”Insert Reason Code NOTE: Only those conditions listed will qualify for a parking space.If reason Code #4 is listed above, please indicate the type of device Physician Name First Last Physician Signature Medical License Number Phone NumberOffice Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EVIDENCE OF PRIOR APPROVAL FOR DISABILITY PLACARD OR REGISTRATION PLATE (MUST HAVE HP PLATE OR PLACARD AT TIME OF THIS APPLICATION)Year, Make and Model of Vehicle Color Registration of Vehicle or Placard Number: Applicant Signature DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920REASON CODES 1. BLINDNESS 2. DOES NOT HAVE FULL USE OF ONE OR BOTH ARMS 3. CANNOT WALK 200 FEET WITHOUT STOPPING TO REST 4. CANNOT WALK WITHOUT THE USE OF, ASSISTANCE, A BRACE, CANE, CRUTCH, ANOTHER PERSON, PROSTETHIC DEVICE, WHEELCHAIR OR OTHER ASSISTIVE DEVICE 5. RESTRICTED BY LUNG DISEASE TO SUCH EXTENT THAT THE PERSONS FORCED (RESPIRATORY) EXPIRATORY VOLUME FOR ONE SECOND, WHEN MEASURED BY SPIROMETRY, IS LESS THAN ONE LITER OR THE ANTERIAL OXYGEN TENSION IS LESS THAN 60 MM/HG ON ROOM AIR AT TEST 6. USES PORTABLE OXYGEN 7. HAS CARDIAC CONDITION TO THE EXTENT THAT THE PERSONS FUNCTIONAL LIMITATIONS ARE CLASSIFIED IN SEVERITY AS CLASS III OR CLASS IV ACCORDING TO THE STANDARDS SET FORTH VY THE AMERICAN HEART ASSOCIATION. 8. IS SEVERLY LIMITED IN HIS OR HER ABILITY TO WALK DUE TO AN ARTHRITIC, NEUROLOGICAL OR ORTHOPEDIC CONDITION.
