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A Action Requested - To Be Completed by Health Care Facility
This form is to be used by Health Care Facilities to enroll in Pennsylvania’s Temporary Placard Program, and/or modify their account with PennDOT.
B Current Health Care Facility Information - To Be Completed By Health Care Facility (Complete All)
D Program Requirments, Acknowledgement, Certification and Signature
Health Care Facility Name Type of Facility
Mailing Address City State Zip Code
Name of Program Coordinator (Please Print) Prog. Coordinator's Telephone Program Coordinator's Email Date of Application
The participating Health Care Facility agrees to the following conditions and requirements:
• Health Care Facility must complete and submit this application to the address at the top of this form.
• Health Care Facilities requesting to participate in the program must complete a review process and training session scheduled by
PennDOT once a completed application to participate is received.
• Health Care Facility must have a locked/secured area to store unused Temporary Persons with Disability Parking Placards for issuance
and provide a photograph of the secure location to PennDOT along with the completed Form MV-145P.
• Health Care Facility must have a scanner and ability to email scanned forms and applications to PennDOT within 24 hours of issuance of
the Temporary Persons with Disability Parking Placard.
• Health Care Facility agrees to store placard inventory in the designated secured location and limit access to the person signing below.
• Health Care Facility agrees to maintain and report inventory of placards to PennDOT on a monthly basis.
• Health Care Facility agrees to return unused/expired placards to PennDOT upon expiration.
• Health Care Facility agrees to provide PennDOT with scanned images of all completed temporary placard application within 24 hours
of placard issuance.
• Health Care Facility agrees to inform PennDOT of any changes to facility information, program coordinator information and employees
who have authorized access to the temporary placards.
By signing below, I certify that I am the designated program coordinator for the facility named above and I have read the information
provided to me for participation in PennDOT’s Temporary Person with Disability Parking Placard Issuance Program. I agree to comply with
all requirements set forth by PennDOT to participate in this program.
I further certify that I have read and signed this application after its completion, and I swear or affirm that the statements made herein are
true and correct, and that any statement made on or pursuant to this application is subject to the penalties of 18 Pa.C.S. Section 4903
(a)(2) (relating to false swearing), which shall include punishment of a fine not exceeding $5,000, or to a term or imprisonment of not more
than two years, or both.
MV-145P (1-18)
w
ww.dmv.pa.gov
APPLICATION FOR ENROLLMENT/CHANGE
IN TEMPORARY PLACARD PROGRAM FOR
HEALTH CARE FACILITIES
F
or Department Use Only
R
esearch & Support Operations Section • P.O. Box 68592 • Harrisburg, PA 17106-8592
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o Initial Enrollment in Temporary Placard Program - Complete Sections A, B, and D.
o Removal from Temporary Placard Program - Complete Sections A, B, and E.
o Change of Secure Location for Placards Only (New Photo Required) - Complete Sections A, B, and D.
o Change to Health Care Facility Information - Complete Sections A, B, C, and D.
This application
is for (check one):
___________________________________ _______________________ ___________________________________
Printed Name
Title
Signature
E Removal from Temporary Placard Program
I wish to be removed from the Temporary Placard Program for Health Care Facilities. Enclosed are the facility's unused placards along with
this application for removal from the program. I further certify that I have read and signed this application after its completion, and I swear
or affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this application is subject to
the penalties of 18 Pa.C.S. Section 4903(a)(2) (relating to false swearing), which shall include punishment of a fine not exceeding $5,000,
or to a term or imprisonment of not more than two years, or both.
___________________________________ _______________________ ___________________________________
Printed Name
Title
Signature
