Form 10-336 "Licensed Physician's or Organization's Certification for Issuance of a Special License Plate or Certificate for a Person With a Disability" - Arkansas

What Is Form 10-336?

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

Form Details:

  • Released on October 1, 2007;
  • The latest edition provided by the Arkansas Department of Finance & Administration;
  • 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 printable version of Form 10-336 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Finance & Administration.

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Download Form 10-336 "Licensed Physician's or Organization's Certification for Issuance of a Special License Plate or Certificate for a Person With a Disability" - Arkansas

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STATE OF ARKANSAS
LICENSED PHYSICIAN’S OR ORGANIZATION’S CERTIFICATION FOR ISSUANCE
OF A SPECIAL LICENSE PLATE OR CERTIFICATE FOR A PERSON WITH A DISABILITY
If a licensed physician certifying an individual, complete Part 1. If an organization providing transportation for persons with a
disability with conditions in A thought L below, complete Part 2.
Notice to Applicant: The department is required to enter into the permanent record disability types in a manner that will allow
retrieval of such information for statistical use. The photo ID number or driver’s license number of the person with a disability
is necessary to identify and retrieve these statistics.
PART 1: TO BE COMPLETED BY A LICENSED PHYSICIAN AND APPLICANT
(
)
UNLESS APPLICANT IS AN ORGANIZATION
Name of Physician:
Address:
City State Zip:
Name of Person with Disability:
Address:
City State Zip:
If Temporary Placard need Social Security Number, Driver’s
License Number or State Assigned Identification Number:
I hereby certify that the individual listed above is or has been a patient under my care and is disabled either permanently or temporarily as
indicated below.
CIRCLE ONE:
PERMANENTLY
TEMPORARILY
Check the appropriate box or boxes A through L, which defines the patient’s condition(s).
(A) Cannot walk one hundred (100) feet without stopping to rest;
(B) Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair, or
other assistive device;
(C) Is restricted by lung disease to such an extent that the person’s forced respiratory expiratory volume for one (1) second,
when measured by spirometry, is less than one (1) liter, or the arterial oxygen tension is less than sixty (60) mm/hg on room
air at rest;
(D) Uses portable oxygen;
(E) 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 standards set by the American Heart Association;
(F) Spinal cord injury;
(G) Genetic ambulatory disorder;
(H) An amputation;
(I) Spina bifida;
(J) Multiple Sclerosis;
(K) Chronic heart disease;
(L) Other:______________________________________________________________________________________________
If none of the conditions in A though L above applies, list the permanent medical condition that substantially impacts the person’s mobility.
Signature of Physician:
Date
PART 2: TO BE COMPLETED IF APPLICANT IS AN ORGANIZATION
Name of Organization:
Address:
City State Zip:
Federal Employer Identification Number:
(M) This is to certify that the organization above owns or leases vehicles used primarily for transporting persons with disabilities
as defined in items (A) through (L) in Part 1.
Signature of Authorized
Date
Organization Official:
IMPORTANT NOTICE ON BACK
10-336
10/07
STATE OF ARKANSAS
LICENSED PHYSICIAN’S OR ORGANIZATION’S CERTIFICATION FOR ISSUANCE
OF A SPECIAL LICENSE PLATE OR CERTIFICATE FOR A PERSON WITH A DISABILITY
If a licensed physician certifying an individual, complete Part 1. If an organization providing transportation for persons with a
disability with conditions in A thought L below, complete Part 2.
Notice to Applicant: The department is required to enter into the permanent record disability types in a manner that will allow
retrieval of such information for statistical use. The photo ID number or driver’s license number of the person with a disability
is necessary to identify and retrieve these statistics.
PART 1: TO BE COMPLETED BY A LICENSED PHYSICIAN AND APPLICANT
(
)
UNLESS APPLICANT IS AN ORGANIZATION
Name of Physician:
Address:
City State Zip:
Name of Person with Disability:
Address:
City State Zip:
If Temporary Placard need Social Security Number, Driver’s
License Number or State Assigned Identification Number:
I hereby certify that the individual listed above is or has been a patient under my care and is disabled either permanently or temporarily as
indicated below.
CIRCLE ONE:
PERMANENTLY
TEMPORARILY
Check the appropriate box or boxes A through L, which defines the patient’s condition(s).
(A) Cannot walk one hundred (100) feet without stopping to rest;
(B) Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair, or
other assistive device;
(C) Is restricted by lung disease to such an extent that the person’s forced respiratory expiratory volume for one (1) second,
when measured by spirometry, is less than one (1) liter, or the arterial oxygen tension is less than sixty (60) mm/hg on room
air at rest;
(D) Uses portable oxygen;
(E) 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 standards set by the American Heart Association;
(F) Spinal cord injury;
(G) Genetic ambulatory disorder;
(H) An amputation;
(I) Spina bifida;
(J) Multiple Sclerosis;
(K) Chronic heart disease;
(L) Other:______________________________________________________________________________________________
If none of the conditions in A though L above applies, list the permanent medical condition that substantially impacts the person’s mobility.
Signature of Physician:
Date
PART 2: TO BE COMPLETED IF APPLICANT IS AN ORGANIZATION
Name of Organization:
Address:
City State Zip:
Federal Employer Identification Number:
(M) This is to certify that the organization above owns or leases vehicles used primarily for transporting persons with disabilities
as defined in items (A) through (L) in Part 1.
Signature of Authorized
Date
Organization Official:
IMPORTANT NOTICE ON BACK
10-336
10/07
APPLICANTS AND PERSONS DRIVING FOR APPLICANTS WHO REQUEST
A SPECIAL LICENSE PLATE OR SPECIAL CERTIFICATE FOR PERSONS WITH A DISABILITY
The following requirements are provided in accordance with Ark. Code Ann. §27-15-307(7).
• The privilege to park in spaces reserved for persons with disabilities shall be available only when the
vehicle is being used to transport the person for whom the special plate or certificate was issued.
• Special certificates must be displayed on the inside rearview mirror, or on the dashboard, if the vehicle is of
a type that does not have an inside rearview mirror.
• Any individual who provides false information to obtain a special plate or certificate, or assists an
unqualified person in acquiring a special license plate or special certificate shall be deemed guilty of a
Class A misdemeanor.
• Any person who abuses the privileges granted by a special license plate or certificate shall be deemed
guilty of a Class A misdemeanor.
• Any unauthorized vehicle found to be parked in an area designated for the exclusive use of a person with a
disability shall be subject to impoundment by the appropriate law enforcement agency. In addition to
impoundment, the owner of the vehicle shall upon conviction be subject to fine of not less than one
hundred dollars ($100) nor more than five hundred dollars ($500) for the first offense, nor less than two
hundred fifty dollars ($250) nor more one thousand dollars ($1000) for the second and subsequent offense,
plus applicable towing, impoundment, and related fees as well as court costs. Upon the second or
subsequent conviction, the court shall suspend the driver’s license for up to six (6) months. The driver may
apply to the Office of Driver Services of the Arkansas Department of Finance and Administration for a
restricted license during the period of suspension.
• If a person to whom a special certificate or license plate has been issued moves to another state, the person
shall surrender the special certificate or plate to the nearest Revenue Office.
• If a person to whom a special certificate or license plate has been issued dies, the special certificate or
license plate shall be returned to the Revenue Office within thirty (30) days after the death of the person to
whom the special certificate or plate was issued.
• The special certificate issued for the permanently disabled shall expire four (4) years from the last day of
the month in which it was issued. The applicant shall not be required to obtain re-certification of his
qualifying disability in order to renew his special certificate.
• The special temporary certificate shall expire three (3) months from the last day of the month in which it
was issued.
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