SP-68 (R4/13)
STATE OF NEW JERSEY
APPLICATION FOR TEMPORARY PLACARD
INITIAL APPLICATION RECERTIFICATION APPLICATION* $4.00 fee (payable to NJ MVC) attached.
SECTION A: APPLICANT INFORMATION
Name of Applicant: ______________________________ Temporary Placard No: ________________
(for recertification*)
Street Address: _________________________________________________
City, State, Zip Code: __________________________________________
Driver License Number: __________________________________
Date of Birth: _________ Sex: ______ Eye Color: ______Ht: _______ Wt: ________
SECTION B: MEDICAL PRACTITIONER’S CERTIFICATION
Name of Medical Practitioner: _____________________________Street Address: _______________________________________
City, State, Zip Code: __________________________________________ Telephone number: _____________________
National Provider Identification No. (NPI #): ______________________________ (required)
By law, eligibility for a Temporary Placard is limited to persons who have temporarily lost the use of one or more limbs, are
temporarily disabled so as to be unable to ambulate without the aid of an assisting device, or whose mobility is otherwise
temporarily limited. (NO OTHER PERSON IS ELIGIBLE FOR A TEMPORARY PLACARD).
I certify, under penalty of law, that my patient (print name)_______________________________________ has been
personally examined by me and
meets the eligibility criteria as specified above and thus meets the requirements for the
receipt of a Temporary Placard.
Signature of Medical Practitioner _________________________________________________________ Date______________
SECTION C: TERMS AND CONDITIONS
1. Pursuant to N.J.S.A. 2C:21-4(a), N.J.S.A. 2C:43-3, and N.J.S.A. 2C:43-6, making a false statement or providing misinformation on
an application to obtain or facilitate the receipt of license plates or placards for persons with disabilities is a fourth degree crime and
a person who has been convicted of this offense may be subject to pay a fine not to exceed $10,000 and a term of imprisonment of
up to 18 months.
2. The temporary placard must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a designated
wheelchair symbol parking space and must be removed when the vehicle is in motion.
3. The Motor Vehicle Commission requires the applicant to be recertified by a qualified medical practitioner to extend the temporary
placard.*
4. Temporary placards are to be used exclusively for the person named on this application. The placard is nontransferable and will be
revoked if used by any other person. If the temporary placard is no longer used by the person named on the application, it must be
returned to the issuing Police Department.
5.
* The temporary placard is valid for no longer than 6 months from the date of issue and can only be recertified once, for a period
not to exceed 6 months.
BY SIGNING BELOW, I AGREE WITH THE TERMS AND CONDITIONS OF THIS APPLICATION.
Applicant’s Signature: ____________________________________________________Date: ___________
FOR USE BY POLICE CHIEF
CHIEF SIGNATURE ___________________________MUNICIPALITY ______________________ FEE PAID
TEMPORARY PLACARD # ___________________ISSUE DATE _________________EXPIRATION DATE_________________
P.O. Box 015
Trenton, New Jersey 08666-0015
888-486-3339 (NJ Toll Free)
609-292-6500 (Out-of-State)
