Fillable APPLICATION FOR DISABILITY PARKING CERTIFICATE (Minnesota Auto & Driver's License of Brainerd)

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APPLICATION FOR DISABILITY PARKING CERTIFICATE (Minnesota Auto & Driver's License of Brainerd)

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APPLICATION FOR DISABILITY PARKING CERTIFICATE
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
FOR CENTRAL OFFICE USE ONLY
Phone: (651) 297-3377 Web: dvs.dps.mn.gov
Does applicant have a Minnesota Identification Card?
Is applicant a Minnesota Licensed driver?
Yes
Yes
No
No
MN License/ID Number
If no MN DL or ID please explain:
Date of Birth
Full Name (Please Print) Last, First and Middle
Has applicant ever had a Minnesota Disability Parking Certificate
Yes
No
Minn. disability license plates?
NoYes
List certificate and/or plate #:
Check here if this application is for two parking certificates* Check here if this application is for a second parking certificate
*Two certificates are not an option if applicant has disability license plates
Limit 2 per applicant without disability license plates.
DISABLED INDIVIDUAL SECTION
To be completed by or for the person with a disability
Street Address
City State Zip
Please Explain:
Other;DamagedStolenLost
If applying for replacement, check reason:
Certificate Type:
Fee: $5 ea.
Fee: $5 ea.
No Fee
No Fee
Temporary 1 to 6 Months
Short Term 7 to 12 Months
Long-Term 13 to 71 Months
Permanent Physical disability issued for 6 years
Certificate Expiration Date
Month Year
/
Must Specify
Must Specify
Must Specify
g
g
g
IMPORTANT!
If no date is indicated the certificate
will be issued for the minimum
duration of certificate type.
Deputy Stamp
The applicant must meet one or more of the definition(s) of a "physically disabled person" described below:
• Check which definition(s) the applicant meets. Cognitive disabilities do not qualify (see back)
• Listing "symptoms" such as Back Pain, Leg Pain, etc. will require further explanation, causing delays in issuance
• Incomplete/missing information will cause significant delays in issuance
The Applicant
1.
9.
7.
8.
6.
5.
4.
3.
2.
Has a cardiac condition to the extent that the applicant's functional limitations are classified in severity as Class III or
Class IV according to the standards set by the American Heart Association.
Uses portable oxygen
Has an arterial oxygen tension (PAO ) of less than 60 mm/Hg on room air at rest.
Has lost an arm or leg and does not have or cannot use an artificial limb.
Is restricted by a respiratory disease to such an extent that the applicant's forced (respiratory) expiratory volume for one second, when measured by
spirometry, is less than one liter.
Is the applicant qualified, in all medical respects, to exercise reasonable and ordinary control over a motor vehicle?
Yes
Yes, with adaptive equipment
No, please specify:
Failure to answer this question will result in a request for a medical report.
I certify, by my signature as a licensed Physician, Physician's Assistant, Advanced Practice Registered Nurse, Chiropractor, or Physical Therapist that
in my professional opinion
(Patient's Name) meets the definition of physically disabled person and is entitled to
a disability parking certificate. I would be guilty of a misdemeanor and subject to a fine of $500 for fraudulently certifying the applicant.
Due to disability, uses a wheelchair or cannot walk without the aid of:
Another Person; A Walker; A Cane; Crutches; Braces; A Prosthetic Device; or other Assistive Device _______________________________;
(Specify Diagnosis of condition causing Disability):
Has a disability that would be aggravated by walking 200 feet under normal environmental conditions to an extent that would be life-threatening
This condition is:
Due to disability cannot walk 200 feet without stopping to rest
This condition is:
Disability Definitions 6-9 below must state the specific diagnosis of the condition causing disability.
Cannot walk without a significant risk of falling
This condition is:
HEALTH PROFESSIONAL MEDICAL STATEMENT SECTION
2
Street Address, City, State and Zip Code
Signature & Title
Date
Print Name
Telephone Number
Signature:
I hereby certify the above information is complete and accurate to the best of my knowledge. I also give permission to the Health Professional to supply the
information requested.
Date:
$5 Fee Paid
$10 Fee Paid (2 Tags)
No Fee Paid (Perm.)
*Non-residents may apply for temporary disability parking certificates or use the parking certificate issued in their state of residence.
PS2005 (08/2019)
- over -
This application may be submitted at any Deputy Registrar motor vehicle office in Minnesota or by mail to:
Minnesota Department of Public Safety
Driver and Vehicle Services Division
445 Minnesota Street
St. Paul, MN 55101-5164
The information provided by the applicant and health professional are required by state and federal guidelines.
1 to 6 months: Temporary certificate, 7 to 12 months: Short-term certificate, 13 to 71 months: Long-term certificate. The disability must be
re-certified before a new or subsequent parking certificate will be issued.
Persons with a permanent disability are issued a 6 Year Certificate. Renewal does not require a Health Professional's signature, but may be
selected randomly to re-certify eligibility.
If a certificate is requested due to specific medical condition related to pregnancy that could be aggravated by walking to the extent that the
life or health of the person or fetus may be endangered a Temporary certificate may be issued, not to exceed expected length of pregnancy.
The parking certificate is valid as specified by the Health Professional's statement.
If a Health Professional extends the length of the disability there is no fee for the subsequent parking certificate, however, along with the
Health Professional’s signature, the medical statement is required and must clearly state that it is an extension for a previously certified
disability.
Frequently Asked Questions
WHAT PRIVILEGES DOES THE CERTIFICATE PROVIDE? (Reference Minnesota Statute 169.345)
A vehicle that prominently displays the parking certificate may be parked by or solely for the benefit of a physically disabled person: in a
designated disability parking space; in a non-restricted metered parking space without obligation to pay the meter fee, and without regard to
time limitation unless otherwise posted; or in a non-metered time limited passenger vehicle space unless otherwise posted.
M.S. 169.345 does not permit parking: in designated no parking spaces; in parking spaces reserved for specified purpose; where there is a
local ordinance which prohibits parking on any street or highway for the purpose of creating a Fire lane; or to provide for the accommodation of
heavy traffic during morning or afternoon rush hours. For privileges in other jurisdictions, please contact the appropriate jurisdiction.
WHO IS ELIGIBLE FOR THE DISABILITY PARKING CERTIFICATE?
Any Minnesota resident who meets one or more of the definitions of a “physically disabled person” listed on the front of this application.
The parking certificate is provided to assist persons with a physical disability and provide better access to public places and facilities.
Only one parking certificate is issued per disabled individual if you also display license plates. You may qualify for two (2) certificates if you do
not have disability license plates. Parking certificates are valid until the last day of the month indicated on the certificate.
If you have further questions regarding this application, contact the Driver and Vehicle Services Division at (651) 297-3377. If you have questions
regarding other services provided by Driver and Vehicle Services or Deputy Registrar Locations, please call (651) 297-2005, or TTY (651) 282-6555.
You may also find DVS information at: dvs.dps.mn.gov
NOTICE: All information supplied on this form is collected under the authority of Minnesota Statutes, and will be used only by authorized Driver and Vehicle
Services Division personnel to determine eligibility for the issuance of a Disability Parking Certificate and driving privileges. All data collected is private and may
not be issued to anyone except law enforcement personnel (name/address information only) or the applicant.
- over -
MISUSE OF PARKING PRIVILEGE
Any unauthorized use or reproduction of the Department issued Disability Parking Certificate is subject to the revocation of parking privilege. A
person who is convicted of misusing the certificate is guilty of a misdemeanor and subject to a fine. Knowingly allowing the misuse of the
certificate or disability license plates shall result in the cancelation of disability parking privileges.
WHAT IF I MISPLACE/LOSE MY CERTIFICATE?
To obtain a replacement certificate you need to only complete Section A of this application (fee may be due).
When you report a lost parking certificate, you may be required to identify measures you have taken in order to prevent future losses.
When you report a stolen parking certificate, you may be asked to provide a copy of the police report regarding the theft.
I HAVE HEARD THAT SOME PEOPLE WHO HAVE APPLIED FOR THE PARKING CERTIFICATE HAVE BEEN REQUIRED TO RETEST
FOR THEIR DRIVER LICENSE. IS THAT TRUE?
YES. If a person with a driver’s license applies for a disability parking certificate, the Department of Public Safety may check the driver’s license
record. If the department has no record of the disability, certification must be made that the disability will not interfere with his/her driving ability.
The department may ask the applicant for an interview to determine if any retesting is necessary. The Department of Public Safety has an
obligation to ensure that licensed drivers are qualified to operate a motor vehicle.
HOW DO I USE THE DISABILITY PARKING CERTIFICATE?
The parking certificate is issued to the disabled person, not the vehicle. Therefore, it may be displayed when parking any vehicle you are driving
or the passenger.
The parking certificate is to be displayed on the rear view mirror only when parked. Driving with the parking certificate hanging from the
mirror is illegal and very dangerous. If your disability makes it impractical to hang the parking certificate from the rear view mirror, it may be
placed on the dashboard when parked.
I'M NOT A MINNESOTA RESIDENT, HOW DO I GET A PARKING CERTIFICATE?
Residents of other states that are visiting or temporarily residing in Minnesota may use the parking certificate provided by their home state or
apply for a Temporary Certificate (6 months maximum). Residents of other states must make an application for Permanent Certificates in their
home states.
445 Minnesota Street - Suite 164
St. Paul, MN 55101-5164
Phone: (651) 297-3377
TDD: (651) 282-6555
Web: dvs.dps.mn.gov
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
APPLICATION FOR COMMERCIAL DISABILITY PARKING CERTIFICATE
Rev. 08/2019
Applications (new and renewal) for commercial disability parking certificates must be made in a written request format explaining
the proposed certificate usage in conjunction with the transportation of disabled individuals, as well as internal controls (i.e.,
ensuring proper accountability) of the certificates.
1. To apply for an organization parking certificate, an agency must submit a written statement on letterhead stationary. Typically,
these applications are made by public or private social service agencies, care centers and nursing homes that have a frequent
business need to transport numerous disabled clients. Certificates cannot be issued to taxi or limousine services, as their
disabled patrons should have their own personal parking certificates. Also, an agency must certify that the commercial
certificate will be used solely for the benefit of a physically disabled person so defined in Minnesota Statute 169.345.
2. The statement must explain to the department's satisfaction how the agency meets the following criteria:
a) Identify vehicles that certificates will be used in when practical
b) State the organizations internal controls for managing/accounting for the certificates
c) State that the organization will immediately notify DVS in the case of lost or stolen certificates
d) State that the organization will contact DVS immediately of any abuse or suspected abuse of certificates issued to the
organization;
e) State that the organization is aware that failure to abide by the above listed requirements may well result in the revocation of
all certificates issued
3. There is a fee of $5 per commercial disability parking certificate requested. Organization parking certificates are issued for
three-year periods.
4. The organization's Federal Employer Identification Number (FEIN) must be provided for processing
When renewing a certificate(s), please include the 6-digit number on your current certificate
and FEIN
Organization certificates cannot be issued until all information is furnished and all fees have been paid.
Driver and Vehicle Services Division Disability Services Unit 445 Minnesota St, Ste. 164
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APPLICATION FOR DISABILITY PARKING CERTIFICATE (Minnesota Auto & Driver's License of Brainerd)

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Completed 27 February 2021

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