CURRENT MAILING ADDRESS
LOG NUMBER
INSTITUTIONAL/ORGANIZATIONAL
DISABLED PARKING PLACARD
APPLICATION
MED 011 (10/10/2019)
For Passenger Vehicles and Pickup/Panel Trucks Only
Purpose: Use this form to apply for institutional/organizational disabled parking placards.
Instructions: Complete the appropriate information below. Return the form to the Department of Motor Vehicles, Data
Integrity, Post Office Box 85815, Richmond, Virginia 23285-5815.
DMV USE ONLY
APPLICANT INFORMATION
INSTITUTION/ORGANIZATION NAME FEDERAL IDENTIFICATION NUMBER (FIN)
Check here if this is a new address. (DMV must have your current mailing address.)
TELEPHONE NUMBER
CITY ZIP CODE
PLACARD INFORMATON
NUMBER OF PLACARD(S) REQUESTED
CERTIFICATION
As an authorized representative of the above institution/organization, I understand that it is unlawful to knowingly make a false
statement on this application and that such a violation will be punished as a Class 2 misdemeanor. I certify that I am aware of the
penalties for violating the disabled parking placard laws, and I understand that misusing or allowing the misuse of the placard(s)
issued to this institution/organization can result in revocation of the placard(s). I also certify that the disabled placard(s) issued to the
above institution/organization will be used only when transporting disabled persons.
AUTHORIZED REPRESENTATIVE NAME (print)
AUTHORIZED REPRESENTATIVE SIGNATURE DATE (mm/dd/yyyy)
DMV USE ONLY
PLACARD NUMBER ISSUE DATE (mm/dd/yyyy) ISSUED BY (print DMV representative name)
The institution or organization requesting the placard must be a hospital, hospice, nursing home, non-profit, or
government entity that serves the disabled community. No medical certification is needed. There is no fee for
Institutional/Organizational Disabled Parking Placard(s). The placard(s) will be mailed within approximately 15 days.
STATE
