APPLICATION FOR ACCESSIBLE PARKING PLACARD
DEPARTMENT OF REVENUE AND TAXATION VEHICLE REGISTRATION BRANCH
HOURS OF OPERATION: 8:00AM – 5:00PM M-F
PLEASE NOTE:
1) Applicants must provide identification (Guam I.D., Naturalization Certification, Green Card, Firearms
I.D., etc.)
2) Upon renewal of a temporary placard, applicant must obtain another certification from a physician.
NAME: SOCIAL SECURITY NO.:
(LAST) (NAME) (INT.)
MAILING ADDRESS:
(STREET NUMBER/P.O.BOX) ZIP CODE
DATE OF BIRTH: HEIGHT: WEIGHT: SEX: PHONE NO.:
1. Do you have a current accessible parking placard? Yes No if yes, Placard No(s):
Expiration Date:
2. Do you have a current accessible parking license plate? Yes No If yes, License Plate Number:
Expiration Date:
3. Please check the appropriate box: [ ] Placard(s) [ ] License Plate
I declare under penalty of perjury that the foregoing is true and correct.
I authorize the release of medical information to process this application.
APPLICANT’S SIGNATURE: DATE: ______
PHYSICIAN’S CERTIFICATION
Section 1. Purpose. The purposes of this act are to establish a uniform system for accessible parking for persons with disabilities to enhance
access and the safety of persons who have disabilities, which limit or impair the ability to walk, and to conform to the requirements of the
Americans with Disabilities Act. Accessibility Guidelines as they apply to accessible parking.
LOSS OF USE OF LOWER LIMBS (S):
Condition: ( ) Amputation ( ) Birth Defect Special Equipment ( ) Artificial Limb(s) ( ) Braces
( ) Multiple Sclerosis ( ) Muscular ( ) Cane(s) ( ) Crutch (es)
( ) Paraplegic ( ) Dystrophy ( ) Walker ( ) Wheel Chair
( ) Other __________ ( ) Polio ( ) Other __________________________
RESPIRATORY CONDITION:
[ ] Is restricted by lung disease to such an extent that the person’s forced (respiratory) expiatory volume for one second, when
measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty (60) mm/hg on room air at rest.
EYE(s) CONDITION:
[ ] Has a central visual acuity that does not exceed 20/200 in the better eye, with corrective lens, as measured by the Snellen Test, or
visual activity greater than 20/200, but with a limitation in the field of vision such that the widest diameter of the visual field subtends an
angle not greater than 20 degrees.
HEART CONDITION CLASSIFICATION: (By the standards set by the American Heart Association)
[ ] Class III [ ] Class IV
OTHER DIAGNOSES DISEASED OR DISORDER, WHICH CREATES A SEVERE WALKING MOBILITY LIMITATION
(cannot walk two hundred feet (200’) without stopping to rest due to):
[ ] Arthritic [ ] Neurological [ ] Orthopedic [ ] Other ____________________________
Does the disability affect the applicant’s ability to operate or limit the driving of a motor vehicle: _____________________________
I, the undersigned, being duly licensed to practice in Guam, certify under the penalties of perjury that I am personally aware of the degree of
impaired mobility of the person identified in this application as indicated above. It is my professional opinion that this applicant should
qualify for the issuance of the special Parking Placard having a condition due to the significant physical mobility limitations and/or for the
safety of the applicant.
[ ] APPROVED-PERMANENT DISABILITY
[ ] APPROVED-(TEMPORARY DISABILITY) NOT TO EXCEED SIX (6) MONTHS
[ ] DISAPPROVED (MOBILITY IS NOT AFFECTED BY CONDITIONS(S): _____________________________________
__________________________________ _________________________________________
Physician’s Signature Print Name
__________________________________ __________________________________________
Clinic Address/Telephone
FOR OFFICIAL USE BY DEPARTMENT OF REVENUE AND TAXATION
VEHICLE REGISTRATION BRANCH
[ ] NEW [ ] RENEWAL [ ] REPL.PLACARD NO. ____________ EXP. DATE: __________ PREVIOUS PLACARD NO. ___________
COMMENTS: _____________________________________________________________________________________________
(Rev5/07)
