Form 861 Application for Special Disability Parking Permit - Alaska

Form 861 is a Alaska Department of Administration form also known as the "Application For Special Disability Parking Permit". The latest edition of the form was released in June 28, 2018 and is available for digital filing.

Download a PDF version of the Form 861 down below or find it on Alaska Department of Administration Forms website.

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STATE OF ALASKA
DIVISION OF MOTOR VEHICLES
APPLICATION FOR SPECIAL DISABILITY PARKING PERMIT
PART 1. TO BE COMPLETED BY APPLICANT
(APPLICANT MUST BE THE PERSON NAMED AS “PATIENT” IN PART 2.)
FULL LEGAL NAME OF APPLICANT (PRINTED)
MAILING ADDRESS
CITY / STATE / ZIP
ID OR DRIVER LICENSE NUMBER
STATE
DATE OF BIRTH
SEX
M
F
EMAIL
DAYTIME TELEPHONE NUMBER
(
)
PART 2. TO BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT, NURSE PRACTITIONER OR PODIATRIST
NAME OF PATIENT:
___________________________________________________________________________
To obtain a disability parking permit, the patient must meet one of the following requirements. Please check any that apply.
1.
Cannot walk 200 feet without stopping to rest
2.
Cannot walk without using a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device
3.
Is restricted by lung disease
4.
Uses portable oxygen
5.
Has a cardiac condition classified as Class III or Class IV according to standards set by the American Heart Association
6.
Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition
THIS DISABILITY IS:
PERMANENT
(valid for five years and renewable upon reapplication) (must have valid Alaska ID or License)
TEMPORARY
(valid up to six months and renewable upon reapplication)
Starting Date (mo/yr) __________ Ending Date (mo/yr) __________
Does your patient have a commercial driver license (CDL)?
YES
NO
If YES, does your patient meet the physical requirements under 49 CFR 391.41 to retain their CDL?
YES
NO
I certify as a licensed Alaskan physician, physician assistant, nurse practitioner, or podiatrist that the patient shown as the
applicant in Part 1 meets the definition(s) above and is eligible for a special disability parking permit or license plates with parking
privileges.
AUTHORIZED SIGNATURE
TITLE (CIRCLE ONE)
DATE
Physician
PA
Podiatrist
/
/ 20
Nurse Practitioner
Chiropractor
PRINTED NAME & OCCUPATIONAL LICENSE NUMBER
CITY & ZIP CODE
TELEPHONE NUMBER
(
)
PART 3. DMV USE ONLY
VISITOR/TOURIST
PERMANENT
TEMPORARY
ORGANIZATION
REPLACEMENT - PREVIOUS
PERMIT / PLATE #
NEW PERMIT OR PLATE #
BATCH
OFFICE
Date
LOGIN ID
Date
Supervisor LOGIN ID
alaska.gov/dmv
Form 861 (Rev. 06/28/2018)
STATE OF ALASKA
DIVISION OF MOTOR VEHICLES
APPLICATION FOR SPECIAL DISABILITY PARKING PERMIT
PART 1. TO BE COMPLETED BY APPLICANT
(APPLICANT MUST BE THE PERSON NAMED AS “PATIENT” IN PART 2.)
FULL LEGAL NAME OF APPLICANT (PRINTED)
MAILING ADDRESS
CITY / STATE / ZIP
ID OR DRIVER LICENSE NUMBER
STATE
DATE OF BIRTH
SEX
M
F
EMAIL
DAYTIME TELEPHONE NUMBER
(
)
PART 2. TO BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT, NURSE PRACTITIONER OR PODIATRIST
NAME OF PATIENT:
___________________________________________________________________________
To obtain a disability parking permit, the patient must meet one of the following requirements. Please check any that apply.
1.
Cannot walk 200 feet without stopping to rest
2.
Cannot walk without using a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device
3.
Is restricted by lung disease
4.
Uses portable oxygen
5.
Has a cardiac condition classified as Class III or Class IV according to standards set by the American Heart Association
6.
Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition
THIS DISABILITY IS:
PERMANENT
(valid for five years and renewable upon reapplication) (must have valid Alaska ID or License)
TEMPORARY
(valid up to six months and renewable upon reapplication)
Starting Date (mo/yr) __________ Ending Date (mo/yr) __________
Does your patient have a commercial driver license (CDL)?
YES
NO
If YES, does your patient meet the physical requirements under 49 CFR 391.41 to retain their CDL?
YES
NO
I certify as a licensed Alaskan physician, physician assistant, nurse practitioner, or podiatrist that the patient shown as the
applicant in Part 1 meets the definition(s) above and is eligible for a special disability parking permit or license plates with parking
privileges.
AUTHORIZED SIGNATURE
TITLE (CIRCLE ONE)
DATE
Physician
PA
Podiatrist
/
/ 20
Nurse Practitioner
Chiropractor
PRINTED NAME & OCCUPATIONAL LICENSE NUMBER
CITY & ZIP CODE
TELEPHONE NUMBER
(
)
PART 3. DMV USE ONLY
VISITOR/TOURIST
PERMANENT
TEMPORARY
ORGANIZATION
REPLACEMENT - PREVIOUS
PERMIT / PLATE #
NEW PERMIT OR PLATE #
BATCH
OFFICE
Date
LOGIN ID
Date
Supervisor LOGIN ID
alaska.gov/dmv
Form 861 (Rev. 06/28/2018)
How Do I Apply?
Complete the application for a special disability parking permit (Form 861) Part 1 available at your local DMV or online at
Alaska.gov/dmv. A licensed physician, physician’s assistant, nurse practitioner, or podiatrist must complete Part 2 of the form
certifying your qualifying conditions.
Who Is Eligible?
Individuals with a temporary or permanent disability are eligible for a special disability parking permit when they meet one of the
following requirements:
Cannot walk 200 feet without stopping to rest;
Cannot walk without using a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device;
Are restricted by lung disease;
Use portable oxygen;
Have a cardiac condition classified as Class III or Class IV according to standards set by the American Heart Association;
Are severely limited in ability to walk due to an arthritic, neurological, or orthopedic condition.
Permit or Plates?
Individuals who experience a temporary disability are eligible to obtain a special disability parking permit to park in designated
parking spaces. Individuals with a permanent disability may obtain either a special disability parking permit or disability license
plates. Registration and taxes are waived for the first set of disability license plates. Full fees are required for second or subsequent
sets of disability license plates.
Where Do I Hang the Special Disability Parking Permit?
Hang the special disability parking permit from your rearview mirror when parked in a designated parking space. Be sure to remove
the permit from your rearview mirror before driving since it can obstruct your vision.
When Does My Special Disability Parking Permit Expire?
Permanent special disability parking permits are issued up to five years and are renewable in your local DMV office. Temporary
disability parking permits are issued up to six months and renewable upon reapplication and doctor certification. The expiration
date is printed on the permit and expires on the last day of the month shown on the permit.
Who Can Use My Special Disability Parking Permit or Plates?
Your special disability parking permit allows you to park in designated parking areas. Anyone transporting the holder of a special
disability parking permit may also park in designated parking when the holder of the permit enters or exits the vehicle.
(907) 269-5551
alaska.gov/dmv
Form 861 (Rev. 06/28/2018)

Download Form 861 Application for Special Disability Parking Permit - Alaska

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