Motor Vehicle Administration
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
For more information, please call: 410-768-7000 (to speak with a customer agent).
TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov
VR-210
(04-13)
Please read instructions on back carefully before completing form.
A. Requested Service: q Lost placard(s) q Stolen Placard(s) Placard number(s)______________________________________
Police Report # of Stolen Placard(s):_________________ Jurisdiction Reported: __________________________________
Parking Placard (Blue) Temp. Parking Placard (Red) License Plate: Motorcycle Plates:
q One q Two q One q Two q One q One q Two
B. Customer Identifying Information - Individual with a Disability
Driver’s License Number: Date of Birth:
Social Security # (optional): Telephone # E-mail Address
First Name: Middle Name: Last Name:
Residence Street Address: City: County: State: Zip Code:
Mailing Street Address (if different): City: County: State: Zip Code:
Sex:
q Male
q Female Race: (optional, check all that apply) q Black q White q Hispanic q Asian
q Native Hawaiian/Pacic Islander q American Indian/Alaskan Native
Attention: I/We certify the statements made herein are true and correct to the best of my/our knowledge, information and belief. I/We understand it is illegal for anyone to
park in any parking space designated for a person with a disability, other than an individual who has submitted and obtained a certication from the MVA, that authorizes
the use of a designated parking space. I/We also understand that the individual who has been certied to have a disability must have a current disability certication card
in his or her possession when using a disability placard or plate.
I further understand that applying for a disability placard or plate and by execution of this authorization, I give permission to my doctor to release to the Motor Vehicle
Administration all medical information relative to the qualication requirements that established my eligibility to obtain the disability placard or plate. Additionally, I agree
to release the MVA from any and all liability that may arise from the collection and storage of medical information, in the procurement of this application. This authorization
will not expire unless all disability placards and plates in my possession are expired or I have returned all placards and plates for cancellation.
Signature of Individual with Disability or Guardian of individual with disability Date
C. Disability Certication Information (doctor’s use only - see disability codes on back)
Please note if your patient has a temporary disability, you should only recommend a temporary placard for a period of 1-6 months. If an extension is required, your patient
can apply for an additional period of disability, for up to six months. This will require the approval of the appropriate clinician. A permanent disability status should be
reserved for conditions that will not improve.
TYPE OF DISABILITY:
q PERMANENT q TEMPORARY
Patient Name: Disability Code: Length of temporary disability (Temp. placard only)
q 1 mo q 2 mo q 3 mo q 4 mo q 5 mo q 6 mo
Reason for temporary disability (Temp. placard only):
Type of Doctor:
q Licensed Physician q Licensed Chiropractor q Licensed Optometrist q Licensed Podiatrist
q Licensed Nurse Practitioner q Licensed Physician’s Assistant
Doctor’s or Nurse Practitioner’s Name (printed): Signature Date:
Ofce Address:
City: County: State: Zip Code:
Telephone Number: E-mail Address: Medical License No.: State of Issue: Expiration Date:
Application for Maryland Parking Placards/License Plates for Individuals with a Disability
Vehicle #1 Motorcycle #1 Motorcycle #2
Vehicle Identication Number: Vehicle Identication Number: Vehicle Identication Number:
Title Number: Title Number: Title Number:
Tag # Exp. Date Tag # Exp. Date Tag # Exp. Date
Owner: Owner: Owner:
Co-Owner: Co-Owner: Co-Owner:
D. Vehicle Owner Information - By signing below, I certify that I understand that my vehicle may be parked in a parking space reserved for a disabled person only when
the individual named above is present and in possession of a current Disability Certication Card.
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Form Completion Instructions:
Section A – Requested Service(s)
Please check the boxes as appropriate. An individual with a disability may apply for:
One placard
One regular disability plate
One placard and one regular disability plate
Two placards
In addition, up to two motorcycle disability plates can be requested with any combination listed above.
An individual with a Temporary disability may apply for:
One or two temporary placards (red)
Note: The vehicle owner must be the individual with a disability in order to qualify for issuance of a disability plate. If the individual with a disability is
not the owner or co-owner, you must apply for a disability placard.
Note: If your placard(s) have been lost or stolen, please check the appropriate box in Section A and indicate the number(s) of the lost or stolen
placard(s). If your placard(s) were stolen, you must indicate the police report number and jurisdiction reported.
Parking Placard (Blue) - Complete Sections B and C. A licensed doctor, nurse practitioner or physician’s assistant must complete Section C (see
Note below).
Temporary Parking Placard (Red) - Complete Sections B and C. A licensed doctor, nurse practitioner or physician’s assistant must complete Section
C (see Note below).
License Plates or Motorcycle Plates - Complete Sections B, C and D. A licensed doctor, nurse practitioner or physician’s assistant must complete
Section C. You may only request a disability plate or motorcycle plate(s) if the vehicle is titled in the name of the individual with a disability.
Transporters of an Individual with a disability may park in designated disability parking spaces by using the individual with disabilities parking
placard. Transporters of an individual with a disability may not obtain a disability plate.
Note:
A doctor’s certication may not be required if the individual has a disability that meets the denition of code 6 or V.
For a replacement placard, only complete Sections A and B. For replacement plates, complete Sections A, B and D.
For temporary placards, Disability Code 10 is to be used.
Permanent Disability Codes 1-9
1. Has lung disease to such an extent that forced (respiratory) expira-
tory volume for one second, when measured by spirometry, is less
than one liter, or arterial oxygen tension (p02) is less than 60 mm/hg
on room air at rest.
2. Has cardiovascular disease limitations classied in severity as Class
III or Class IV according to standards set by the American Heart
Association.
3. Is unable to walk 200 feet without stopping to rest.
4. Is unable to walk 200 feet without the use of, or the assistance from,
a brace, cane, crutch, another person, prosthetic device, or other
assistance device.
5. Requires a wheelchair for mobility.
6. Has lost an arm, hand, foot, or leg. (See Note D)
7. Has lost the use of an arm, hand, foot or leg.
8. Has a permanent disability, that adversely impacts the ambulatory
ability of the applicant and which is so severe that the person would
endure a hardship or be subject to a risk of injury if the privileges
accorded a person for whom a vehicle is specially registered were
denied.
9. Has a permanent impairment of both eyes so that: 1) The central
vision acuity is 20/200 or less in the better eye, with corrective
glasses, or 2) There is a eld defect in which the peripheral eld has
contracted to such an extent that the widest diameter of visual eld
subtends an angular distance no greater than 20 degrees in the better
eye. (See Note C)
10. Temporary Placard (Red) requested
Disability is not permanent but would substantially impair the person’s
mobility or limit or impair the person’s ability to walk for at least three
weeks, and is so severe that the person would endure a hardship or
be subject to risk of injury if the Temporary Permit was denied.
V. (Reserved for use by veterans with 100% disability) The Veterans
Administration has certied by letter that the applicant has a 100%
service connected disability.
Notes:
A. A licensed physician, licensed nurse practitioner or licensed physician’s assistant may certify all qualifying conditions listed.
B. A licensed chiropractor or licensed podiatrist may certify disability codes 3 through 8 and 10.
C. A licensed optometrist may certify only qualifying conditions regarding vision.
D. The person with a disability may self-certify the conditions listed under Disability Code 6 by appearing in person with proper identication. In this
situation, only the disabled person’s name and Disability Code must be recorded. If, however, a doctor certies the loss of a limb, the doctor must
complete all of Section C.
Visit your local MVA full service ofce with the completed form. If someone other than the applicant submits the application for Disability Plates or
Placards they must provide a state issued ID. Applications may also be mailed with the appropriate fees to the Motor Vehicle Administration,
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062. Attn: Disability Unit
Instructions:
Form Purpose: An individual with a disability may use this form to request placards, license plates and/or motorcycle plates that will allow a vehicle
in which he/she is riding to park in a parking space reserved for the disabled. Two types of placards are available: Temporary Placards (red), which
are valid for a period of up to 6 months; and Parking Placards (blue), which are valid for four years. An applicant may request a parking placard,
license plate and motorcycle plates at the same time. See the Form Completion Instructions below.
Fee Information:
There is not a fee for the placard(s). A request for a disability plate and/or motorcycle plate requires the assessment of the substitute/replacement
tag fee. Please submit your completed application along with the appropriate $20.00 fee. If requesting a disability plate and/or motorcycle plate(s)
and it’s time to renew your vehicle registration, the registration renewal fee is also required.