CERTIFICATION 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”
NOTE: Only those conditions listed will qualify for a parking space.
EVIDENCE OF PRIOR APPROVAL FOR DISABILITY PLACARD OR REGISTRATION PLATE (MUST HAVE HP PLATE OR PLACARD AT TIME OF THIS APPLICATION)
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.