APPLICATION FOR DISABILITY PARKING CERTIFICATE

A P P L I C A T I O N F O R D I S A B I L I T Y P A R K I N G C E R T I F I C A T EMINNESOTA DEPARTMENT OF PUBLIC SAFETY DRIVER AND VEHICLE SERVICESFOR CENTRAL OFFICE USE ONLY445 Minnesota Street, St. Paul, MN 55101-5164 Phone: (651) 297-3377 Web: applicant have a Minnesota Identification Card?Is applicant a Minnesota Licensed driver?YesYesNoNoLicense/ID Number----Date of BirthFull Name (Please Print) Last, First and MiddleHas applicant ever had a Minnesota DISABILITY PARKING CertificateYesNoMinn. DISABILITY license plates?NoYesList CERTIFICATE and/or plate #:Check here if this APPLICATION is for two PARKING certificates*Check here if this APPLICATION is for a second PARKING CERTIFICATE *Two certificates are not an option if applicant has DISABILITY license platesLimit 2 per applicant without DISABILITY license INDIVIDUAL SECTION To be completed by or for the person with a disabilityStreet AddressCityStateZipPlease Explain:Other;DamagedStolenLostIf applying for replacement, check reason: CERTIFICATE Type:Fee: $5 : $5 FeeNo FeeTemporary 1 to 6 MonthsShort Term 7 to 12 MonthsLong-Term 13 to 71 Months6-year CERTIFICATE For permanent disabilitiesCertificate Expiration DateMonthYear/Must SpecifyMust SpecifyMust SpecifygggIMPORTANT!

1 to 6 months: Temporary certificate, 7 to 12 months: Short-term certificate, 13 to 71 months: Long-term certificate.The disability must be re-certified before a new or subsequent parking certificate will be issued. Persons with a permanent disability are issued a 6 Year Certificate.Renewal does not require a Health Professional's signature, but may be

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  Certificate, Renewal, Parking, Disability, Disability parking certificate

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