Applicant’s Name: ______________________________ Date of Birth: _________________
NOTE: The physician needs to make sure the application is completed in the disabled
person’s name (not parent, caretaker, guardian or P.O.A.).
ALL RESPONSES BELOW MUST BE PROVIDED BY YOUR PHYSICIAN
Dear Doctor:
This is an application to allow your patient to utilize a disability parking placard. The individual’s ability to
maintain a driver’s license will not affect their ability to obtain a placard. If you determine that your patient’s
medical condition renders them a threat to their own safety or to the safety of others using the roadways,
please indicate this below.
Comments:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________
_________________________________
Criteria
A. Cannot walk without the use of a brace, cane, crutch, wheelchair, prosthetic device or another
person.
B. Suffers from lung disease to such an extent that 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.
C. Needs portable oxygen.
D. Has a cardiac condition to the extent that your functional limitations are classified in severity as
Class III or Class IV according to standards set by the American Heart Association.
E. Legally blind, visual acuity of 20/200 or worse in the better eye with corrective lenses.
Temporary Condition - Expected duration: _______ months.
(Minimum two (2)
months; maximum twelve
(12) months)
Long Term Condition (one to three years duratio
n): _______ years.
Permanent Condition (in excess of three years).
By signing this application, I certify that I am currently treating this applicant for a medical condition that
meets at least one of the above listed criteria.
___________________________________ ____ ______________________________
Certifying Physician’s Full Name RI Medical License Number
___________________________________ __________________________________
Addre
ss (City/Town/State/Zip Code) Telephone
___________________________________ __________________________________
Medical Sp
ecialty Certifying Physician’s Signature
NOTE: It is a misdemeanor to knowingly make false statements to a public official and is
punishable by fines up to $1,000.00 or up to one year in jail. Rhode Island General
Law §11-18-1.
LENGTH OF DISABILITY (check one):
PHYSICIAN CERTIFICATION (please print):
