Transcription of APPLICATION FOR DISABILITY PARKING CERTIFICATE
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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!
The personal information you provide to apply for a disability parking certificate is classified by 18 U.S.C section 2721 and the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13 and is subject to the disclosure in
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