Fillable Application for Vehicle License Plates and/or Placard for (The State of New Jersey)

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Application for Vehicle License Plates and/or Placard for (The State of New Jersey)

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  • 20 check-boxes
  • 37 other fields

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Application for Vehicle License Plates
and/or Placard for Persons
with a Disability
Vis
it us at www.NJMVC.gov
New Jersey is an Equal Opportunity Employer
SP-41 (R11/20)
Management Operation Services
Special Plate Unit
225 East State Street
P.O. Box 015
Trenton, NJ 08666
609-292-6500 ext. 5061
This is my:
Initial Application Recertification Application Replacement Application
I am applying for:
License Plates Placard Both
SECTION A: PERSONS WITH A DISABILITY IDENTIFICATION CARD INFORMATION
Name of Person with a Disability
Street Address
City, State, Zip Code
Driver License Number
Expiration Date
Date of Birth
Sex
Eye Color
Daytime Telephone Number
I acknowledge that I hold a Commercial Driver License (CDL) and that this application may result in a medical review that could result in a
decision that may affect my New Jersey CDL privilege.
Current Plate Number: _____________________________________________________________________________________________
Current Placard Number (for recertification applications): __________________________________________________________________
SECTION B: WHEELCHAIR SYMBOL LICENSE PLATES (Photocopy of Registration Required)
Registered Vehicle Owner’s Name
Vehicle Plate Number
Expiration Date
Registered Vehicle Owner’s Driver License Number
Expiration Date
Street Address
City, State, Zip Code
Relationship to the Disabled Applicant:
Self Spouse Parent Guardian Other (Please Specify): _______________
SECTION C: REPLACEMENT PLATES, PLACARD AND/OR IDENTIFICATION CARD
License Plates Placard Identification Card
Vehicle Plate Number
Expiration Date
Placard Number
Expiration Date
Check One:
Lost – attach a notarized statement of loss.
Damaged – return plate(s), placard, and/or both
Stolen – plate(s), placard – attach police report
SECTION D: CERTIFICATION OF STATEMENTS
I certify, under penalty of law, that the statements on this application are true.
Signature of Registered Vehicle Owner: ______________________________________________________ Date: _____________________
Signature of Person with a Disability: ________________________________________________________ Date: _____________________
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Application for Vehicle License Plates
and/or Placard for Persons
with a Disability
Visi
t us at www.NJMVC.gov
New Jersey is an Equal Opportunity Employer
SP-41 (R11/20)
SECTION E: MEDICAL PRACTITIONER OR DISABLED VETERAN CERTIFICATION
Name of Medical Practitioner or Representative of the U.S.D.V.A.
Street Address
City, State, Zip Code
Daytime Telephone Number
Required prescription attached Required letterhead attached (ONLY for medical practitioners who are not authorized to write
prescriptions OR a representative of the U.S.D.V.A.)
By law, eligibility for license plates and/or a placard for persons with a disability is limited to the following conditions. (NO OTHER PERSON
IS ELIGIBLE FOR LICENSE PLATES AND/OR A PLACARD).
Patient Name (please print): _________________________________________________________________________________________
1. Has lost the use of one or more limbs as a consequence of paralysis, amputation, or other permanent disability.
2. Is severely and permanently disabled and cannot walk without the use of or assistance from a brace, cane, crutch, another person,
prosthetic device, wheelchair or other assistive device.
3. Suffers from lung disease to such an extent that the applicant’s forced (respiratory) expiratory volume for one second, when measured
by a spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air at rest; or uses portable
oxygen.
4. 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 standards set by the American Heart Association.
5. Is severely and permanently limited in the ability to walk because of an arthritic, neurological, or orthopedic condition; or cannot walk two
hundred feet without stopping to rest.
6. Has a permanent sight impairment of both eyes as certified by the NJ Commission for the Blind (Placard only).
I CERTIFY, UNDER PENALTY OF LAW, THAT MY PATIENT (print name) ___________________________________________________
HAS BEEN PERSONALLY EXAMINED BY ME AND MEETS THE ELIGIBILITY CRITERIA AS SPECIFIED IN ITEM NUMBER(S) (select
from above) ________________ AND THUS MEETS THE REQUIREMENTS FOR THE RECEIPT OF LICENSE PLATES AND/OR A
PLACARD FOR PERSONS WITH A DISABILITY.
Signature of Medical Practitioner or Representative of the U.S.D.V.A.: ________________________________________________________
SECTION F: TERMS AND CONDITIONS
1. Pursuant of N.J.S.A. 2C: 21-4(a), N.J.S.A. 2C: 43-3, and N.J.S.A. 2C: 43-6, making a false statement or providing misinformation on an
application to obtain or facilitate the receipt of license plates or placards for persons with disabilities is a fourth-degree crime and a
person who has been convicted of this offense may be subject to pay a fine not to exceed $10,000 and a term of imprisonment of up to
18 months.
2. Wheelchair symbol license plates may be issued for one vehicle owned, operated or leased by a person with a disability or family
member providing transportation for that person.
3. Wheelchair symbol license plates must be renewed every year, disability recertification is required every three years.
4. The placard must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a designated wheelchair symbol
parking space and must be removed when the vehicle is in motion.
5. Persons with a Disability Identification Card and placards must be recertified every three years.
6. The Motor Vehicle Commission requires that a person’s disability be recertified by a qualified medical practitioner and their qualification
for license plates/placard as provided under N.J.A.C. 13:20-9.1(a) 4.
7. The persons with a Disability placard and/or license plates are to be used exclusively for a person with a disability named on the
identification card. The identification card is nontransferable and shall be revoked is used by any other person. If the license plate and/or
placard are no longer used by the person named on the identification card, they must be returned to the New Jersey Motor Vehicle
Commission. Abuse of this privilege is cause for revocation of both the license plates and/or the placard.
8. Application for a Persons with a Disability Identification Card shall be submitted to the Motor Vehicle Commission not more than 60 days
following the date upon which a medical professional or representative of the United States Department of Veterans Affairs certifies that
the applicant meets the definition of “persons with a disability.”
I CERTIFY, UNDER THE PENALTY OF LAW, THAT I AGREE WITH THE TERMS AND CONDITIONS OF THIS APPLICATION.
Signature of Registered Vehicle Owner: ______________________________________________ Date: _____________________________
Signature of Person with a Disability: ________________________________________________ Date: _____________________________
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Application for Vehicle License Plates andor Placard for (The State of New Jersey)

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Completed 26 May 2021

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