SP27 (Rev 7/2019)
Please Print or Type Full Legal Name
Middle
Last
A LICENSED PHYSICIAN, ADVANCED PRACTICE REGISTERED NURSE (APRN), OR PHYSICIAN’S ASSISTANT MUST
COMPLETE THIS PORTION
Please print or type and complete in full:
Please check one: Licensed Physician Advanced Practice Registered Nurse (APRN) Physician’s Assistant
Physicians, APRN’s, or Physician’s Assistant: Printed Name:
___________________________________________________________________________________________________________
First Middle Last
Physicians, APRN’s, or Physician’s Assistant: License No. ________________ State _________________
Mailing Address ____________________________________________________________ Telephone No. _____________________
Address City State Zip Code
As a Physician, APRN, Physician’s Assistant for the above-named patient, I hereby certify that the applicant:
1. ☐ Cannot walk two hundred feet without stopping to rest.
2. ☐ Cannot walk without the use of a brace, cane, crutch, wheelchair or prosthetic, or other assistive device, or another person.
3. ☐ Has a cardi
ac condition to the extent that functional limitations are classified as Class III or Class IV according to standards
adopted by the American Heart Association.
4. ☐ Is restricted by a lung disease to such an extent that the person’s forced expiratory volume for 1 second, when measured by a
spirometer, is less than 1 liter, or the arterial oxygen tension is less than 60 millimeters of mercury on room air while the
person is at rest.
5. ☐ Is severely limited in his/her ability to walk because of an arthritic, neurological, or orthopedic condition.
6 ☐ Has a visual disability.
7. ☐ Uses portable oxygen.
I further certify that my patient’s condition is a:
Temporary Disability (6 months or less) must indicate length of time not to exceed 6 months beginning _____________ and
ending _________________
Moderate Disability (reversible but disabled longer than 6 months)
Must indicate length of time not to exceed 2 years beginning _________________ and ending _________________
Permanent Disability (irreversible, permanently disabled in his/her ability to walk, certification is valid indefinitely).
Physicians, APRN’s, or Physician’s Assistant: Signature ______________________________________________________________
Date __________________________
Plate/Placard Number(s) ________________ ___________________
DMV Tech Initials _____________ Date Issued ________________
