Form MED10 "Disabled Parking Placard or License Plates Application" - Virginia

What Is Form MED10?

This is a legal form that was released by the Virginia Department of Motor Vehicles - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 23, 2017;
  • The latest edition provided by the Virginia Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MED10 by clicking the link below or browse more documents and templates provided by the Virginia Department of Motor Vehicles.

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Download Form MED10 "Disabled Parking Placard or License Plates Application" - Virginia

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MED 10 (02/23/2017)
DISABLED PARKING PLACARD
OR LICENSE PLATES
APPLICATION
Purpose:
Persons with disabilities use this form to apply for a disabled parking placard or disabled parking license plates.
Instructions: For a parking placard OR replacement placard ID card, submit this form with applicable fees ($5.00 - parking placard
& ID card / $2.00 - replacement placard ID card only). Placard or replacement ID card will be mailed to you within
approximately 15 days. Only one placard may be issued to a customer.
For disabled parking license plates, submit this form, a completed License Plate Application (VSA 10) and applicable
fees.
For placard and/or license plates, submit forms and fees to any Customer Service Center, DMV Select or mail to DMV,
Data Integrity, P.O. Box 85815, Richmond, VA 23285-5815.
APPLICANT INFORMATION (person with disability)
FULL LEGAL NAME (last) (first) (middle) (suffix)
DMV ASSIGNED NUMBER OR SOCIAL SECURITY NUMBER
NOTE: If you enter a residence or mailing address that is other than what is currently on DMV's system, complete an "Address Change Request" (ISD 01).
CURRENT RESIDENCE ADDRESS (SEE NOTE ABOVE)
CITY
STATE
ZIP CODE
CITY OR COUNTY OF RESIDENCE
DAYTIME TELEPHONE NUMBER OR CELL PHONE NUMBER
(
)
MAILING ADDRESS (if different from above) (SEE NOTE ABOVE)
CITY
STATE
ZIP CODE
BIRTH DATE (mm/dd/yyyy)
GENDER
HAIR COLOR
EYE COLOR
HEIGHT
WEIGHT
MALE
FEMALE
FT
IN
LBS
APPLICATION TYPE
APPLICATION FOR ORIGINAL:
DISABLED PARKING LICENSE
DISABLED PARKING PLACARD AND
DISABLED PARKING
*
*
PLACARD
PLATE (complete form VSA 10)
LICENSE PLATE (complete form VSA 10)
(check one)
*
Only permanently disabled persons or institutions that transport individuals with disabilities may obtain disabled license plates.
APPLICATION FOR REPLACEMENT:
DISABLED PARKING PLACARD
DISABLED PLACARD ID CARD
DISABLED LICENSE PLATE
(check applicable)
Lost
Stolen
Destroyed/Mutilated
Never Received
REASON FOR REPLACEMENT - original was:
DISABLED PARKING LICENSE PLATES (HP) (check one)
The vehicle on which HP plates will be used is specifically equipped and used for transporting groups of physically disabled persons.
I am the vehicle owner and the parent/legal guardian of a disabled dependent(s). List the name of each disabled person below.
APPLICANT CERTIFICATION (person with disability)
I understand that misuse, counterfeiting, or alteration of disabled placards may result in fines up to $1000.00 and up to 6 months in jail
and/or revocation of disabled parking privileges. I certify that I have a (check one):
disability that limits or impairs
Temporary
Permanent
my ability to walk or creates a safety concern while walking.
I also understand that the disabled parking placard or plates issued to me cannot be loaned to anyone, including family members or friends, to
benefit a person other than myself.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of
perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
DMV USE ONLY
15-DAY PLACARD RECEIPT NUMBER
TEMPORARY PLACARD (up to 6 months)
Placard
Placard ID
License Plate
Replacement
ORIGINAL
REISSUE
Lost
Stolen
Destroyed/Mutilated
PLACARD EXPIRATION DATE (mm/dd/yyyy)
PERMANENT PLACARD (5 years)
ORIGINAL
REISSUE
EMPLOYEE STAMP
(Medical professional certification required.)
Replacement
RENEWAL
Placard
Placard ID
License Plate
(No medical professional certification required.)
Lost
Stolen
Destroyed/Mutilated
HP PLATES
ORIGINAL PLATES
DUPLICATE PLATES
REISSUE PLATES
submit completed
Lost
Unreadable (letters/numbers unclear)
form VSA 10
Destroyed
Plates never received
MED 10 (02/23/2017)
DISABLED PARKING PLACARD
OR LICENSE PLATES
APPLICATION
Purpose:
Persons with disabilities use this form to apply for a disabled parking placard or disabled parking license plates.
Instructions: For a parking placard OR replacement placard ID card, submit this form with applicable fees ($5.00 - parking placard
& ID card / $2.00 - replacement placard ID card only). Placard or replacement ID card will be mailed to you within
approximately 15 days. Only one placard may be issued to a customer.
For disabled parking license plates, submit this form, a completed License Plate Application (VSA 10) and applicable
fees.
For placard and/or license plates, submit forms and fees to any Customer Service Center, DMV Select or mail to DMV,
Data Integrity, P.O. Box 85815, Richmond, VA 23285-5815.
APPLICANT INFORMATION (person with disability)
FULL LEGAL NAME (last) (first) (middle) (suffix)
DMV ASSIGNED NUMBER OR SOCIAL SECURITY NUMBER
NOTE: If you enter a residence or mailing address that is other than what is currently on DMV's system, complete an "Address Change Request" (ISD 01).
CURRENT RESIDENCE ADDRESS (SEE NOTE ABOVE)
CITY
STATE
ZIP CODE
CITY OR COUNTY OF RESIDENCE
DAYTIME TELEPHONE NUMBER OR CELL PHONE NUMBER
(
)
MAILING ADDRESS (if different from above) (SEE NOTE ABOVE)
CITY
STATE
ZIP CODE
BIRTH DATE (mm/dd/yyyy)
GENDER
HAIR COLOR
EYE COLOR
HEIGHT
WEIGHT
MALE
FEMALE
FT
IN
LBS
APPLICATION TYPE
APPLICATION FOR ORIGINAL:
DISABLED PARKING LICENSE
DISABLED PARKING PLACARD AND
DISABLED PARKING
*
*
PLACARD
PLATE (complete form VSA 10)
LICENSE PLATE (complete form VSA 10)
(check one)
*
Only permanently disabled persons or institutions that transport individuals with disabilities may obtain disabled license plates.
APPLICATION FOR REPLACEMENT:
DISABLED PARKING PLACARD
DISABLED PLACARD ID CARD
DISABLED LICENSE PLATE
(check applicable)
Lost
Stolen
Destroyed/Mutilated
Never Received
REASON FOR REPLACEMENT - original was:
DISABLED PARKING LICENSE PLATES (HP) (check one)
The vehicle on which HP plates will be used is specifically equipped and used for transporting groups of physically disabled persons.
I am the vehicle owner and the parent/legal guardian of a disabled dependent(s). List the name of each disabled person below.
APPLICANT CERTIFICATION (person with disability)
I understand that misuse, counterfeiting, or alteration of disabled placards may result in fines up to $1000.00 and up to 6 months in jail
and/or revocation of disabled parking privileges. I certify that I have a (check one):
disability that limits or impairs
Temporary
Permanent
my ability to walk or creates a safety concern while walking.
I also understand that the disabled parking placard or plates issued to me cannot be loaned to anyone, including family members or friends, to
benefit a person other than myself.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of
perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
DMV USE ONLY
15-DAY PLACARD RECEIPT NUMBER
TEMPORARY PLACARD (up to 6 months)
Placard
Placard ID
License Plate
Replacement
ORIGINAL
REISSUE
Lost
Stolen
Destroyed/Mutilated
PLACARD EXPIRATION DATE (mm/dd/yyyy)
PERMANENT PLACARD (5 years)
ORIGINAL
REISSUE
EMPLOYEE STAMP
(Medical professional certification required.)
Replacement
RENEWAL
Placard
Placard ID
License Plate
(No medical professional certification required.)
Lost
Stolen
Destroyed/Mutilated
HP PLATES
ORIGINAL PLATES
DUPLICATE PLATES
REISSUE PLATES
submit completed
Lost
Unreadable (letters/numbers unclear)
form VSA 10
Destroyed
Plates never received
MED 10 (02/23/2017)
page 2
The front of this form must be completed before
APPLICANT FULL LEGAL NAME (last, first, middle, suffix)
the medical professional signs the certification.
NOTE: (This page does not have to be completed to renew permanent placards.)
DISABILITY TYPE
Temporarily limited or impaired beginning date (mm/dd/yyyy) _____________ and ending date (mm/dd/yyyy)_________________(not to
exceed 6 months).
Permanently limited or impaired. A permanent disability as it relates to disabled parking privileges shall mean: a condition that limits or impairs
movement from one place to another or the ability to walk as defined in Virginia Code §46.2-1240, and that has reached the maximum level of
improvement and is not expected to change even with additional treatment.
LICENSED PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER MEDICAL CERTIFICATION
Reason this patient's ability to walk is limited or impaired or creates a safety condition while walking. (check below)
Cannot walk 200 feet without stopping to rest.
Is restricted by lung disease to such an extent that forced
(respiratory) expiratory volume for one second, when measured by
Uses portable oxygen.
spirometry, is less than one liter, or the arterial oxygen tension is
Cannot walk without the use of or assistance from any of the following:
less than 60 millimeters of mercury on room air at rest.
another person, brace, cane, crutch, prosthetic device, wheelchair, or
Has been diagnosed with a mental or developmental amentia or
other assistive device.
delay that impairs judgment including, but not limited to, an autism
Has a cardiac condition to the extent that functional limitations are
spectrum disorder.
classified in severity as Class III or Class IV according to standards set
Has been diagnosed with Alzheimer's disease or another form of
by the American Heart Association.
dementia.
Is severely limited in ability to walk due to an arthritic, neurological, or
Is legally blind or deaf.
orthopedic condition.
Other condition that limits or impairs the ability to walk. (Specific condition description must be specified below).
LICENSED CHIROPRACTOR OR PODIATRIST MEDICAL CERTIFICATION
Reason this patient's ability to walk is limited or impaired or creates a safety condition while walking. (check below)
Is severely limited in ability to walk due to an arthritic, neurological
Cannot walk 200 feet without stopping to rest.
or orthopedic condition.
Cannot walk without the use of or assistance from any of the
following: another person, brace, cane, crutch, prosthetic device,
wheelchair, or other assistive device.
Other condition that limits or impairs the ability to walk. (Specific condition description must be specified below).
LICENSED MEDICAL PROFESSIONAL CERTIFICATION
I certify and affirm that the described applicant is my patient, whose ability to walk, based on my examination, is limited or impaired or creates a safety
concern while walking as described above.
I further certify and affirm that to the best of my knowledge and belief, all information I have presented in this form is true and correct, that any documents I
have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and
affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
Physician
Chiropractor
Podiatrist
Nurse Practitioner
Physician Assistant
MEDICAL PROFESSIONAL NAME (print)
OFFICE TELEPHONE NUMBER
OFFICE FAX NUMBER
(
)
(
)
LICENSE TYPE
LICENSE NUMBER
STATE ISSUING LICENSE (required) LICENSE EXPIRATION DATE (required)
MEDICAL PROFESSIONAL SIGNATURE
DATE (mm/dd/yyyy)
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