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APPLICATION FOR DISABILITY PLATES/PLACARD |
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BMV ENTERED |
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Disability Placard or Disability Plate(s) |
Permanent Re-Issue |
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BMV Use Only |
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For Plates, please attach a copy of your current registration |
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Placard#_________________ |
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Applicant |
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Name: |
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_______________________ |
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Mailing |
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_______________________ |
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Address: |
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Plate #___________________ |
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Issue Date: ________________ |
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DOB: |
Driver’s License or ID # and Expiration Date: |
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Exp. Date: ________________ |
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Returned#: ________________ |
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Phone: |
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State of Issue: |
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Replaced#: ________________ |
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Contact Name: |
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Issued by: ________________ |
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Applicant’s Signature: |
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Date: |
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Completed forms may be |
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processed at any BMV branch |
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office or mailed/faxed to: |
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Veterans, please visit the Bureau of Veterans’ Services website at |
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http://www.maine.gov/dvem/bvs for information on state and federal benefits your military |
Bureau of Motor Vehicles |
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service may have earned you. |
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Disability Clerk |
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APPLICANT’S STATEMENT OF UNDERSTANDING |
29 State House Station |
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Augusta, ME 04333-0029 |
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I may park in a disability parking space when the vehicle is occupied by the disabled |
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person and the vehicle is properly displaying disability plates or a placard. I understand |
TTY Users call Maine Relay 711 |
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permanent disability applications are valid until my current driver’s license or state ID card |
FAX: |
(207) 624-9204 |
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expires; if I want to continue my permanent disability parking credentials beyond that |
Phone: |
(207) 624-9000 |
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expiration, I must complete the top portion of an application, mark it as Permanent Re- |
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Ext. 52149 |
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Issue and visit a BMV branch office or mail/fax it to the BMV main office. |
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MEDICAL PROVIDER’S STATEMENT |
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Condition is: |
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Permanent |
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Temporary for a period of _______ months (6 months maximum) |
Please check one of the following conditions:
Cannot walk two hundred feet without stopping to rest.
Cannot walk without the use of, or assistance from another person or the use of a brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.
Is restricted by lung disease to such an extent that the person’s forced expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty m/hg on room air at rest.
Uses portable oxygen.
Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV according to the standards set by the American Heart Association.
Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition. Is recovering from childbirth: TEMPORARY PLACARD ONLY - check appropriate box below
Cesarean delivery – valid for 1 week following receipt of application;
For the birth of a preterm infant, valid for ____________ (specify length of time, not to exceed 6 months)
Medical Provider: Physician Physician’s Assistant |
Nurse Practitioner |
Registered Nurse |
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Printed Name: |
Date: |
Medical Lic #: |
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Signature: |
Phone: |
Fax #: |
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Address: |
21-Day Temp # Issued: |
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