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
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 Certication 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:
Ofce 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 Certication 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
ti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
First Name: Middle Name: Last Name:
Date of Birth: Driver’s License/Identication 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/Identication 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 Certication 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:
Ofce 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 Certication 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
ti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
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/Identication 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/Identication 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 Certication 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:
Ofce 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 Certication 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
ti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
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/Identication 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/Identication Number:
Reason for temporary disability (Temp.
VR-210 (8-21)
placard only:)
For quickest processing of your disability placard upload this form to our online services portal at:
https://mymva.maryland.gov/TAP/IND/?Link=Disability
Apply to register to vote with your driver’s license transaction. For details ask your customer agent.
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Form Completion Instructions:
An individual with a permanent disability may apply for:
• One placard, or
• One regular disability plate, or
• One placard and one regular disability plate, or
• Two placards
In addition, up to two motorcycle disability plates can be requested with any combination listed above.
A doctor’s certification may not be required if the individual has a disability that meets the definition 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)
expiratory 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 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, licensed podiatrist or licensed physical therapist 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.
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, which are
valid for a period of up to 6 months; and Permanent Parking Placards which are valid until the death of the disabled individual. An applicant may
request a parking placard, license plate and motorcycle plates at the same time.
Fee Information:
Placard: There is not a fee for the placard(s).
Plates: 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.
An individual with a Temporary disability may apply for:
One or two temporary placards
Parking Placard – Complete Sections A,B and approved medical provider complete Section C. (See Note below).
License Plates or Motorcycle Plates – Complete Sections A, B, D and approved medical provider complete Section C. (See Note below). (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).
Note: