MVR-37A Front (Rev. 1/19)
Fee $5.00 Each (Limit 2)
MEDICAL CERTIFICATION FOR APPLICATION & RENEWAL OF DISABILITY PARKING PLACARD
North Carolina Division of Motor Vehicles
3148 Mail Service Center, Raleigh, NC 27697-3148
Application instructions:
1. Applicant must select the number of placards desired. (Limit of two per applicant.)
2. Applicant must complete and sign only the applicant section.
- Parent may sign for minors.
- If signing with a Power of Attorney, a certified copy must be attached or shown at the time of issuance.
3. Medical provider must complete and sign the medical provider's section if applicable or present documentation from the U.S. Department of Veterans
Affairs.
4. Application and fee ($5.00 per placard) can be taken to your local License Plate Agency or mailed to the address above.
5. Medical recertification not required for persons 80 years of age or older at the time of renewal.
I would like: ONE placard $5.00 TWO placards $10.00
APPLICANT'S NC DRIVER LICENSE / ID NUMBER
APPLICANT'S/ORGANIZATION'S PRINTED NAME
MAILING ADDRESS IF DIFFERENT FROM ABOVE
APPLICANT'S/ORGANIZATION REPRESENTATIVE'S SIGNATURE
MEDICAL PROVIDER'S SECTION
Disability parking placards and license plates are governed by the Motor Vehicle Laws of North Carolina General Statute Chapter 20, Article 2A.
Afflicted, Disabled or Handicapped Persons. G. S. 20-37.5 Definitions (2) "Handicapped" shall mean a person with a mobility impairment who, as
determined by a licensed medical provider: (check all that apply)
Cannot walk 200 feet without stopping to rest
Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device
Is restricted by lung disease to such an extent that the person’s forced (respiratory) expiratory volume of one second, when measured by spirometry, is
less than one liter, or the arterial oxygen tension is less than 60 mm/hg on room air at rest
Uses portable oxygen
Has a cardiac condition to the extent that the person's functional limitations are classified in severity as Class III or Class IV according to standards set by
the American Heart Association
Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition
Is totally blind or whose vision with glasses is so defective as to prevent the performance of ordinary activity for which eyesight is essential, as certified by a
licensed ophthalmologist, optometrist, or the Division of Services for the Blind
The medical provider certifies that the applicant qualifies for one of the parking placards listed below: (circle one)
1. Disability Parking Placard- Placard issued for 5 years and requires medical provider recertification upon renewal.
2. Temporary Disability Parking Placard - Placard issued for 1 to 6 months then expires. If needed beyond expiration a new application must be completed
and requires recertification from a medical provider.
Temporary placard expiration in months (circle one): 1 2 3 4 5 6
3. Total and Permanent Disability Parking Placard – Placard issued for 5 years and does not require medical provider recertification upon renewal.
MEDICAL PROVIDER'S SIGNATURE
MEDICAL PROVIDER'S ADDRESS
MEDICAL PROVIDER'S PRINTED NAME
MEDICAL PROVIDER'S PHONE NUMBER
MEDICAL PROVIDER'S LICENSE NUMBER
