This statement is only valid for 90 days.
Missouri law requires this form to be completed for new applicants and every eighth year for renewal applicants to obtain disabled person license plates
or placards. Section 301.142.1, RSMo, denes “physically disabled” as listed below. Please complete the form in full. At least one disability must
be marked. You must personally sign this form. A stamped signature or signature of a nurse is not acceptable. Disabilities other than those listed below
do not qualify the applicant for disabled person license plates or placards.
See reverse for more information
__ __ /__ __ /__ __ __ __
Patient’s
Information
Name (Last, First, Middle) Driver License Number or Date of Birth (MM/DD/YYYY) Gender
Federal Employers I.D. Number
Street, Rural Route, or P.O. Box City State Zip Code
Physician’s
Information
Printed Name of Physician or Licensee Physician’s Phone Number
License Number State of License
(__ __ __) __ __ __ - __ __ __ __
r Adv. Practice Registered Nurse r Physician Assistant
r Chiropractor r Physical Therapist
r Podiatrist r Optometrist
r Licensed Physician
It is a Class B misdemeanor for an advance practice registered nurse, licensed physician, chiropractor, physician assistant, podiatrist,
physical therapist, or optometrist to:
1. Issue, sign, or furnish a statement to any person who does not meet one or more of the conditions above; or
2. Issue, sign, or furnish a statement to any person for a condition above, the diagnosis of which is outside his or her scope of license.
A Class B misdemeanor is punishable by a ne not to exceed $500 or imprisonment not to exceed 6 months.
I certify that I have physically examined the person listed above and determined he or she is physically disabled for the reason(s) indicated
above as required by Section 301.142.1, RSMo in order to obtain disabled license plates or placards.
Signature and Certification
Personal signature of advance practice registered nurse, licensed physician, chiropractor, physician assistant, Date (MM/DD/YYYY)
podiatrist, physical therapist, or optometrist. (A stamped signature or signature of a nurse is not acceptable).
__ __ /__ __ /__ __ __ __
r The person cannot ambulate or walk 50 feet without stopping to rest due to a severe and disabling arthritic, neurological, orthopedic
condition, or other severe and disabling condition.
r The person cannot ambulate or walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device,
wheelchair, or other assistive device.
r The person is restricted by a respiratory or other disease to such an extent that the person’s forced respiratory expiratory volume for
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.
r The person uses portable oxygen.
r The person has a cardiac condition to the extent that the person’s functional limitations are classied in severity as Class III or
Class IV according to the standards set by the American Heart Association.
r The person is blind as dened in Section 8.700, RSMo.
r Permanent Disability
r Temporary Disability* Provide Expiration Date (MM/DD/YYYY) __ __ /__ __ /__ __ __ __
* A date is required or the minimum of 30 days will be used. This date cannot exceed 180 days from the date of this statement.
See reverse side for additional information.
Select each disability as dened in Section 301.142.1, RSMo that applies. A person’s age shall not be a factor in determining a disability.
Disability
Form
1776
Physician’s Statement for Disabled
License Plates or Placards
