A Public Service Agency
APPLICATION FOR
DISAbLED PERSON PLACARD OR PLATES
(NOTE: Forlost,stolen,ormutilateddisabledpersonordisabledveteranlicenseplatesorplacard,pleasecompleteanApplicationFor
ReplacementPlates,Stickers,andDocuments[formREG156availableonDmVWeb]).
Please check at least one of the following boxes:
DisabledPersonLicensePlates
No Fee
No Fee
NOTE:DisabledPersonlicenseplatescanonlybeassignedtovehicles
currentlyregisteredinthenameofthequalifieddisabledperson.
TemporaryParkingPlacard
$6
TravelParkingPlacard
No Fee
TravelParkingPlacardsareissuedtoapplicantswithpermanentdisabilities.ACaliforniaresident,applyingforaTravelParkingPlacard,
musthaveapermanentparkingplacardordisabledpersonordisabledveteranlicenseplates,butnotboth.TravelParkingPlacardsare
issuedtonon-residentsfornomorethan90daysandtoCaliforniaresidentsfornomorethat30days.
PermanentParkingPlacard
AllapplicantsmustcompletesectionsA, bandE.DisabledPersonLicensePlateapplicantsmustalsocompletesectionC.
A. APPLICANT’S TRuE FuLL NAME(PLEASE PRINT)
LASTNAmE FIRSTNAmE mIDDLENAmE ORORGANIzATIONNAmE
DATEOFbIRTh(NOTREqUIREDFORORGANIzATIONS)
RESIDENCEORORGANIzATIONADDRESSAPT/SPACE
DRIVERLICENSE/IDNUmbER(NOTREqUIREDFORORGANIzATIONS)
CITY
STATE
zIPCODE
DAYTImETELEPhONENUmbER
mAILINGADDRESS
APT/SPACE
CITY
month
Day
Year
( )
STATE
zIPCODE
b. WereyoueverissuedDisabledPersonorDisabledVeteranLicensePlatesoraPermanentParkingPlacardinCalifornia?
yES –A doctor’s disability certification is NOT required, unless the placard was canceled by the department or is no longer on
record.Thedisabledpersonorveteranlicenseplatesorpermanentplacardnumberis________________________________.
NO –Adoctor’scertificationisrequired.ThedoctormustcompletesectionsF andGonthereverseside.
C. IF yOu ARE APPLyING FOR DISAbLED PERSON LICENSE PLATES,pleasedescribethevehiclethatisregisteredtoyouon whichyouwillputthedisabledpersonlicenseplates:
LICENSEPLATENUmbER
VEhICLEIDENTIFICATIONNUmbER
mAkE
CoMMerCIaLVehICLeexeMPTIon
Iamrequestinganexemptionfromweightfeesforthevehicledescribedabove.Itweighslessthan8,001poundsunladenandistheonly
commercialvehicleforwhichIhaverequestedthisexemption.
Yes No
D.
IMPORTANT INFORMATION – PLEASE READ
IT IS ILLEGAL
•Toallowsomeonetouseyourplacard,ifyouarenotinthevehicle.
•Topossessordisplayacounterfeitplacard.
•Foranindividualtohavemorethanonepermanentplacard.
•Toalteraplacardorplacardidentificationcard.
•Toprovidefalseinformationtoobtainaplacardordisabledpersonplates.
•Toforgeadoctor’ssignature.
IMPORTANT
•Theonlylegaluseofaplacardisitsdisplaybythepersontowhomitisissued.Thedisabledpersondoesnothavetoownordrivethe
vehicletousetheplacard.
•Placardabuseormisusecanresultinthecancellation andrevocation oftheplacardandlossoftheprivilegesitprovides.
•Placardanddisabledpersonlicenseplateabuseisamisdemeanorpunishablebyafineofnotlessthan$250,notmorethan$1,000,or
byimprisonmentinacountyjailfornotmorethan6months,orbybothfineandimprisonment.Thecourtmayalsoimposeacivilpenalty
ofnotmorethan$1,500,foreachconviction.
•Toalter,forge,counterfeitorfalsifyaplateisafelonypunishableby16monthsto3yearsinastateprisonorupto1yearinthecountyjail.
•Apersonwhoforges,counterfeits,falsifiesorpasses,attemptstopass,acquires,possesses,sells,orattemptstosellagenuineor
counterfeitplacard,orapersonwhodisplayswithfraudulentintent,orcausesorpermitstobedisplayedaforged,counterfeitorfalse
placardisguiltyofamisdemeanoranduponconvictionshallbepunishedbyimprisonmentinthecountyjailfor6monthsorbyafineof
notlessthan$500ormorethan$1,000,orbybothfineandimprisonment.Thecourtmayalsoimposeacivilpenaltyofnotmorethan
$3,500foreachconviction.
•Theplateand/orplacardmustbesurrenderedtoDMVwithin60daysofthedeathofthedisabledperson.
•Anyinformationcontainedinthisapplicationwillbeavailabletolocalpubliclawenforcementorthelocalagenciesresponsibleforthe
enforcementofparkingregulations.
E. APPLICANT’S SIGNATuRE AND CERTIFICATION
I have read the “Important Information” in section D and I fully understand and take responsibility for the use of the
disabledpersonplacardorplatesthatareissuedtome.
Icertify(ordeclare)underpenaltyofperjuryunderthelawsoftheStateofCaliforniathatalltheforegoingistrueandcorrect.Ialsocertify
thatIamadisabledpersonperCVC295.5(asdefinedinsectionF)andthatIam
Permanently or Temporarilydisableddueto:_____________________________________________________________.
EXECUTEDAT(CITY,STATE)
REG195(REV.8/2008) WWW
DATE
SIGNATUREOFAPPLICANT
Clear Form
Print
F. DOCTOR’S CERTIFICATION OF DISAbILITy
Afulllegibledescriptionoftheillnessordisabilitymustbeprovidedfornumbers3,4,5,6and7below.Alicensedphysician,surgeon,
physician’sassistant,nursepractitioner,orcertifiednursemidwife,maycertifytoitems1–7,alicensedchiropractormaycertifytoitems
5–7only,andalicensedphysicianorsurgeonwhospecializesindiseasesoftheeyeoralicensedoptometristmayonlycertifytoitem8.
mypatient___________________________________________meetstherequirementsofadisabledpersonfoundinCVC295.5ashe
(PRINTEDNAmEOFPATIENT)
orshesuffersfromthefollowing:
1. A lung disease to the extent that forced (respiratory) expiratory volume for one second when measured by spirometry is less
thanoneliteror arterialoxygentension(pO2)islessthan60mm/hgonroomairwhilethepersonisatrest.
2. A cardiovascular disease to the extent that the person’s functional limitations are classified in severity as class III or class IV
baseduponstandardsacceptedbytheAmericanheartAssociation.
3.
Adiagnoseddiseaseordisorderwhichsubstantiallyimpairsorinterfereswithmobilitydueto(please print):
Aseveredisabilityinwhichheorsheisunabletomovewithouttheaidofanassistivedevice,whichisdueto(please print):
4.
___________________________________________________________________________________________________.
___________________________________________________________________________________________________.
5. Asignificantlimitationintheuseoflowerextremitiesdueto(please print):
___________________________________________________________________________________________________.
6. Theloss,orlossoftheuseofoneormorelowerextremities.Lossofusedueto(please print):
___________________________________________________________________________________________________.
7. Theloss,orlossoftheuseof,bothhands.Lossofusedueto(please print):
___________________________________________________________________________________________________.
8. Centralvisualacuitydoesnotexceed20/200inthebettereye,withcorrectivelenses,asmeasuredbytheSnellentest,orvisual
acuity that is greater than 20/200, but with a limitation in the field of vision such that the widest diameter of the visual field
subtendsananglenotgreaterthan20degrees.
Please check the appropriate box(es).
PERMANENT PLACARD
TEMPORARy PLACARD
Validuntil:month____Day____Year_____
(Cannotexceed6months)
G. aUThorIZeDMeDICaLProVIDer’SSIGnaTUreanDCerTIFICaTIon
PRINTAUThORIzEDmEDICALPROVIDER’SLASTNAmEFIRSTNAmEmIDDLENAmE AUThORIzEDmEDICALPROVIDER’SADDRESS
CITY
TraVeLPLaCarD
Validuntil:month____Day____Year_____
(Cannotexceed30daysforaCalifornia
residentand90daysforanon-resident.)
AUThORIzEDmEDICALPROVIDER’SDAYTImETELEPhONE#
(
)
STATEzIPCODE
I certify that I am a
Physician
Surgeon
Chiropractor
optometrist
Physician’s assistant
nurse
Practitioner
CertifiednurseMidwifeandIcertify(ordeclare)underpenaltyofperjuryunderthelawsoftheStateofCaliforniathat
theforegoingistrueandcorrect.IalsocertifythatIwillretaininformationsufficienttosubstantiatethiscertificationandshallmakethat
informationavailableforinspectionbythemedicalboardofCaliforniaatthedepartment’srequest.(CVCSection22511.55).
EXECUTEDAT(CITY,STATE)
DATE
AUThORIzEDmEDICALPROVIDER’SSIGNATURE
MEDICAL LICENSE NuMbER
h. CerTIFICaTIonoFreaDILYoBSerVaBLeanDUnConTeSTeDPerManenTDISaBILITY(DMV USE ONLY)
SIGNATUREOFDmVEmPLOYEE
Whenthisformiscompleted,itmaybemailedto:
LINEDATESTAmP
DmVPlacard
P.O.box942869
Sacramento,CA94269-0001
or submitted to your nearest DmV office. It is recommended that you make an appointment if submitting this form to your nearest
DmVoffice,bycalling1-800-777-0133.
REG195(REV.8/2008) WWW