Application for Parking Permit for Persons with Disabilities
Donna Lent, Town Clerk
Patricia Ryan-Correa, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
TC-03 rev. 6/20
For Additional Information, Please Visit
www.brookhavenny.gov/departments/townclerk
TC-03 Page 2 of 2
Male Female
Expired Parking Permit Tag and required ID MUST be returned with this application. See attached instructions for
additional information. Return completed application with a stamped self-addressed legal-size envelope to: Brookhaven Town
Clerk, One Independence Hill, Farmingville, NY 11738. FAX COPIES OF APPLICATION WILL NOT BE ACCEPTED
Office Use Only Permit No.: Expiration Date: ID Shown:
PART 1: TO BE COMPLETED BY APPLICANT OR PARENT/GUARDIAN IF A MINOR
1. Date:
2.
New Renewal Replacement Damaged
3
. Prior Permit Number:
4. Name: Last First MI 5. Telephone:
6. Address:
7. Mailing Address: (if different from above)
8. Date of Birth: 9. 10. Email Address:
11. Signature of Applicant: If signed by parent/guardian for applicants under the age of 18, please state your relationship to the applicant. If the applicant is 18 years of
age or older and unable to sign, Guardianship papers or Power of Attorney must be provided.
12. Please visit BrookhavenNY.gov/Subscribe to receive information regarding accessibility in the Town of Brookhaven.
PART 2: TO BE COMPLETED BY AUTHORIZED MEDICAL PROFESSIONAL (DIAGNOSIS REQUIRED).
Disabilities must be certified by a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Nurse Practitioner (NP), a
Doctor of Podiatric Medicine
for disabilities related to the foot, or Optometrist
for blindness
13. Name of Physician: 14. Professional License No.: 15. Telephone No.:
16. Address: Number and Street Town State Zip Code
Temporary Disability: Temporary disability, by definition, is any person who is temporarily unable to ambulate without the aide of
an assisting device, i.e. a brace, cane, crutch, prosthetic device, another person, wheelchair or walker. IMPORTANT: Temporary
permits are issued for six (6) months or less regardless of expected recovery date.
17. DIAGNOSIS: Do Not Abbreviate or Use Office Codes 18. Expected Recovery Date:
19. What assistive device is needed?
Permanent Disability: A “severely disabled” person is any person with one or more of the PERMANENT impairments, disabilities
or conditions listed below, which limit mobility.
20. DIAGNOSIS: Do Not Abbreviate or Use Office Codes
21. Please check the conditions that apply:
Uses portable oxygen Legally blind Limited or no use of one or both legs Unable to walk 200 ft. without stopping
Neuromuscular dysfunction that severely limits mobility Class III or IV cardiac conditions (American Heart Association standards)
Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition
Restricted by lung disease to such an extent that for
ced (respiratory) expiratory volume for one second, when measured by
spirometry, is less than one liter or the arterial oxygen tension is less than sixty mm/hg of room air at rest
Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which
imposes unusual hardship in the use of public transportation and prevents the person from getting around without difficulty
EXPLAIN BELOW HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY
________________________________________________________________________________________________________
22. Signature of Physician: (Signature Stamp Will Not Be Accepted) 23. Date: (must be dated within the last 6 months)
