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APPLICANT INFORMATION (person with disability)

MED 10 (02/10/2018) DISABLED PARKING PLACARD OR LICENSE PLATES APPLICATION HP PLATESPERMANENT PLACARD (5 years)RENEWAL (No medical professional certification required.)ORIGINAL (Medical professional certification required.)REISSUE Lost StolenDestroyed/MutilatedORIGINAL PLATES submit completed form VSA 10 DUPLICATE PLATES Destroyed LostREISSUE PLATES Plates never received Unreadable (letters/numbers unclear) I understand that misuse, counterfeiting, or alteration of disabled placards may result in fines up to $ and up to 6 months in jail and/or revocation of disabled parking privileges.

CURRENT RESIDENCE ADDRESS CITY STATE ZIP CODE CITY OR COUNTY OF RESIDENCE DAYTIME TELEPHONE NUMBER OR CELL PHONE NUMBER ... a completed License Plate Application (VSA 10) and applicable fees. ... Data Integrity, P.O. Box 85815, Richmond, VA 23285-5815. MED 10 (07/01/2020) Reason this patient's ability to walk is …

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