Application for Parking Permit for Persons with Disabilities
Donna Lent, Town Clerk
Patricia Ryan-Correa, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
TC-03 rev. 6/20
For Additional Information, Please Visit
www.brookhavenny.gov/departments/townclerk
TC-03 Page 1 of 2
PARKING PERMIT FOR PERSONS WITH DISABILITIES APPLICATION PROCEDURE
If you are a resident of the Town of Brookhaven who qualifies as a severely disabled person, you can obtain a
n application
for a parking permit for persons with disabilities from the Town Clerk’s Office at 1 Independence Hill, Farmingville.
Persons living within the incorporated villages of Patchogue, Port Jefferson, Belle Terre and Bellport must obtain the
application and their permit at their village hall.
Parking permits issued to individuals with a permanen
t disability are valid for five (5) years. Temporary Parking Permits
are valid for a maximum of six (6) months and are issued to any resident who is certified by a physician as being
temporarily unable to walk without the help of an assistive device.
IDENTIFICATION REQUIREMENTS
Applications for New, Renewal and Lost/Stolen Permits must be submitted with copies of one of the following:
Valid Driver’s License
Valid DMV issued Non-Driver Photo ID (NDID)
If you do not have a valid Driver’s License or Non-Driver’s ID, please contact the Town Clerk’s office at (631) 451-9124
or (631) 451-7093 for additional information on accepted proof of identity.
PROOF OF RESIDENCY REQUIREMENTS
If your driver’s license or NDID does not list your current physical address, a utility bill, bank statement or credit card
statement that includes your name and current physical address dated within the last six (6
) months must also be submitted
with your application.
NEW PERMITS
Part I of the application is to be filled out and signed by the applicant. A Parent/Guardian shall sign the application for
applicants under the age of 18. Guardianship papers or Power of Attorney must be provided if the applicant is 18
years of age or older and unable to sign. If your mail is delivered to a P.O. Box, you must also include your street
address on the application. Part II of the application must be completed (including diagnosis and professional license
number) and signed by your physician (MD, DO, NP, PA or DPM). Chiropractors (DC) are not considered
“physicians” under the Vehicle and Traffic Law, Sec. 1203.
You should return the application by mail (NO FAX COPIES OR PHOTOCOPIES) to the address listed on the top
of the application. Mail is processed promptly and you will receive your permit within a few days.
RENEWAL PERMITS
If renewing a permit, the expiring permit MUST BE RETURNED. Part I and Part II of the application must be
completed for all permit renewals. If your permit was issued from another municipality, you must file an application
as a new resident.
You should return the application by mail (NO FAX COPIES OR PHOTOCOPIES) to the address listed on the top
of the application. Mail is processed promptly and you will receive your permit within a few days.
LOST OR STOLEN PERMITS
If your permit was lost or stolen, you must sign a sworn affidavit and have it notarized. You must also complete and
sign Part I of the permit application. (NO FAX COPIES OR PHOTOCOPIES)
The affidavit mentioned above states that you would be issued ONE (1) replacement tag. If the replacement tag is
lost or stolen the Town Clerk’s Office may not issue you another tag. You will have the option of going to the
Department of Motor Vehicles for plates.
If you need additional assistance, please call (631) 451-9124 or (631) 451-7093.
Application for Parking Permit for Persons with Disabilities
Donna Lent, Town Clerk
Patricia Ryan-Correa, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
TC-03 rev. 6/20
For Additional Information, Please Visit
www.brookhavenny.gov/departments/townclerk
TC-03 Page 2 of 2
Male Female
Expired Parking Permit Tag and required ID MUST be returned with this application. See attached instructions for
additional information. Return completed application with a stamped self-addressed legal-size envelope to: Brookhaven Town
Clerk, One Independence Hill, Farmingville, NY 11738. FAX COPIES OF APPLICATION WILL NOT BE ACCEPTED
Office Use Only Permit No.: Expiration Date: ID Shown:
PART 1: TO BE COMPLETED BY APPLICANT OR PARENT/GUARDIAN IF A MINOR
1. Date:
2.
New Renewal Replacement Damaged
3
. Prior Permit Number:
4. Name: Last First MI 5. Telephone:
6. Address:
7. Mailing Address: (if different from above)
8. Date of Birth: 9. 10. Email Address:
11. Signature of Applicant: If signed by parent/guardian for applicants under the age of 18, please state your relationship to the applicant. If the applicant is 18 years of
age or older and unable to sign, Guardianship papers or Power of Attorney must be provided.
12. Please visit BrookhavenNY.gov/Subscribe to receive information regarding accessibility in the Town of Brookhaven.
PART 2: TO BE COMPLETED BY AUTHORIZED MEDICAL PROFESSIONAL (DIAGNOSIS REQUIRED).
Disabilities must be certified by a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Nurse Practitioner (NP), a
Doctor of Podiatric Medicine
(DPM)
for disabilities related to the foot, or Optometrist
(OD)
for blindness
13. Name of Physician: 14. Professional License No.: 15. Telephone No.:
16. Address: Number and Street Town State Zip Code
Temporary Disability: Temporary disability, by definition, is any person who is temporarily unable to ambulate without the aide of
an assisting device, i.e. a brace, cane, crutch, prosthetic device, another person, wheelchair or walker. IMPORTANT: Temporary
permits are issued for six (6) months or less regardless of expected recovery date.
17. DIAGNOSIS: Do Not Abbreviate or Use Office Codes 18. Expected Recovery Date:
19. What assistive device is needed?
PERMANENT DISABILITI
ES
Permanent Disability: A “severely disabled” person is any person with one or more of the PERMANENT impairments, disabilities
or conditions listed below, which limit mobility.
20. DIAGNOSIS: Do Not Abbreviate or Use Office Codes
21. Please check the conditions that apply:
Uses portable oxygen Legally blind Limited or no use of one or both legs Unable to walk 200 ft. without stopping
Neuromuscular dysfunction that severely limits mobility Class III or IV cardiac conditions (American Heart Association standards)
Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition
Restricted by lung disease to such an extent that for
ced (respiratory) expiratory volume for one second, when measured by
spirometry, is less than one liter or the arterial oxygen tension is less than sixty mm/hg of room air at rest
Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which
imposes unusual hardship in the use of public transportation and prevents the person from getting around without difficulty
EXPLAIN BELOW HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY
________________________________________________________________________________________________________
22. Signature of Physician: (Signature Stamp Will Not Be Accepted) 23. Date: (must be dated within the last 6 months)