VR-210-6b(5-18)
Please read instructions on back carefully before completing form.
A. Customer Identifying Information - Individual with a Disability
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
A
pplication for Maryland Parking Placards/ License Plates
Vehicle #1 Motorcycle #1 Motorcycle #2
Title Number: Title Number: Title Number:
D. Vehicle Owner Information - By signing above, 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 Certication Card.
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062
For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.
Type of Doctor: q Licensed Physician ropractor q Licensed Optometrist q Licensed Podiatrist
q Licensed Nurse Practitioner q Licensed Physician’s Assistant q Licensed Physical Therapist
Doctor’s or Nurse Practitioner’s Name (printed): Signature: Date:
Ofce Address:
City: County: State: Zip Code:
Telephone Number: E-mail Address: Medical License No.: State of Issue: Expiration Date:
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:
qPERMANENT qTEMPORARY qDisabled Veteran
B. Requested Service:
qNew qReplacement qLost placard(s) q
Stolen Placard(s)
Placard number(s):_______________________________
Police Report # of Stolen Placard(s):_____________________ Jurisdiction Reported:___________________________
Parking Placard: Temp. Parking Placard: License Plate: Motorcycle Plates
(Available in Glen Burnie Room 104 only):
qOne qTwo qOne qTwo qOne qOne qTwo
C. Disability Certication Information (doctor’s use only - see disability codes on back)
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 cer
tication from the MVA, that authorizes
the use of a designated parking space. I/We also understand that the individual who has been certied to have a disability must have a current disability certication 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 qualication 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
Mail completed application to the Motor Vehicle Administration
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062 Attn: Disability Unit
First Name: Middle Name: Last Name:
Date of Birth: Driver’s License/Identication Number:
Residence Street Address: City: County: State: Zip Code:
Mailing Street Address (if different): City: County: State: Zip Code:
If Guardianship, Guardian’s First Name: Middle Name: Last Name:
Date of Birth: Driver’s License/Identication Number:
VR-210-6b(5-18)
Please read instructions on back carefully before completing form.
A. Customer Identifying Information - Individual with a Disability
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
Application for Maryland Parking Placards/License Plates/Residential Pole for Individuals with a Disability
Vehicle #1 Motorcycle #1 Motorcycle #2
Title Number: Title Number: Title Number:
D. Vehicle Owner Information - By signing above, 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 Certication Card.
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062
For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.
Type of Doctor: q Licensed Physician q Licensed Chiropractor q Licensed Optometrist q Licensed Podiatrist
q Licensed Nurse Practitioner q Licensed Physician’s Assistant q Licensed Physical Therapist
Doctor’s or Nurse Practitioner’s Name (printed): Signature: Date:
Ofce Address:
City: County: State: Zip Code:
Telephone Number: E-mail Address: Medical License No.: State of Issue: Expiration Date:
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 q Disabled Veteran
B. Requested Service:
q New q Replacement q Lost placard(s) q Stolen Placard(s) q Residential Pole (Attach Completed IS-022)
Placard number(s):_______________________________ Police Report # of Stolen Placard(s):_____________________ Jurisdiction Reported:___________________________
Parking Placard: Temp. Parking Placard: License Plate: Motorcycle Plates
(Available in Glen Burnie Room 104 only):
q One q Two q One q Two q One q One q Two
C. Disability Certication Information (doctor’s use only - see disability codes on back)
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 cer
tication from the MVA, that authorizes
the use of a designated parking space. I/We also understand that the individual who has been certied to have a disability must have a current disability certication 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 qualication 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
Mail completed application to the Motor Vehicle Administration
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062 Attn: Disability Unit
First Name: Middle Name: Last Name:
Date of Birth: Driver’s License/Identication Number:
Residence Street Address: City: County: State: Zip Code:
Mailing Street Address (if different): City: County: State: Zip Code:
If Guardianship, Guardian’s First Name: Middle Name: Last Name:
Date of Birth: Driver’s License/Identication Number:
VR-210-6b(5-18)
Please read instructions on back carefully before completing form.
A. Customer Identifying Information - Individual with a Disability
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
Application for Maryland Parking Placards/License Plates/Residential Pole for Individuals with a Disability
Vehicle #1 Motorcycle #1 Motorcycle #2
Title Number: Title Number: Title Number:
D. Vehicle Owner Information - By signing above, 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 Certication Card.
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062
For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.
Type of Doctor: q Licensed Physician q Licensed Chiropractor q Licensed Optometrist q Licensed Podiatrist
q Licensed Nurse Practitioner q Licensed Physician’s Assistant q Licensed Physical Therapist
Doctor’s or Nurse Practitioner’s Name (printed): Signature: Date:
Ofce Address:
City: County: State: Zip Code:
Telephone Number: E-mail Address: Medical License No.: State of Issue: Expiration Date:
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 q Disabled Veteran
B. Requested Service:
q New q Replacement q Lost placard(s) q Stolen Placard(s) q Residential Pole (Attach Completed IS-022)
Placard number(s):_______________________________ Police Report # of Stolen Placard(s):_____________________ Jurisdiction Reported:___________________________
Parking Placard: Temp. Parking Placard: License Plate: Motorcycle Plates
(Available in Glen Burnie Room 104 only):
q One q Two q One q Two q One q One q Two
C. Disability Certication Information (doctor’s use only - see disability codes on back)
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 cer
tication from the MVA, that authorizes
the use of a designated parking space. I/We also understand that the individual who has been certied to have a disability must have a current disability certication 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 qualication 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
Mail completed application to the Motor Vehicle Administration
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062 Attn: Disability Unit
First Name: Middle Name: Last Name:
Date of Birth: Driver’s License/Identication Number:
Residence Street Address: City: County: State: Zip Code:
Mailing Street Address (if different): City: County: State: Zip Code:
If Guardianship, Guardian’s First Name: Middle Name: Last Name:
Date of Birth: Driver’s License/Identication Number:
Reason for temporary disability (Temp.
VR
-
210 (9
-
18)
placard only:)
