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APPLICATION FOR MOBILITY-IMPAIRED PARKING PERMIT …

APPLICATION FOR MOBILITY-IMPAIRED PARKING PERMIT North Dakota Department of Transportation, Motor Vehicle SFN 2886 (6-2021)MOTOR VEHICLE DIVISION ND DEPT OF TRANSPORTATION 608 E BOULEVARD AVE BISMARCK ND 58505-0780 Telephone (701) 328-2725 Website: MOBILITY-IMPAIRED License Plates - $5 fee required for EACH vehicle listed below - DO NOT SEND CASHThis option requires ONE current PARKING PERMIT . **Complete ONLY if you are requesting MOBILITY-IMPAIRED license BE COMPLETED BY APPLICANT (please print)Placard Number(s)For Motor Vehicle Use OnlyApplicant's Legal NameMailing AddressCity StateZip CodeTelephone NumberDriver's License NumberPermanent MOBILITY-IMPAIRED PARKING PERMIT ONLY - no fee requiredNumber of permits requested (maximum amount 2)License Plate NumberYear and Make of VehicleLicense Plate NumberYear and Make of VehicleDuplicate Permanent MOBILITY-IMPAIRED PARKING Permits - $3 EACH - DO NOT SEND CASHC hoose reason for Duplicate: Lost Stolen MutilatedList placard number you have in your possession _____If a law enforcement officer finds that the PERMIT is being improperly used, the officer may report to the director any violation and the director may in the director's discretion, remove the privilege.

The permit is good for 3 months. NOTE: A Qualified Medical Provider who provides a false statement that a person is mobility-impaired for the purpose of that person obtaining a permit under the subsection is guilty of an infraction for which a minimum fine of one hundred dollars must be imposed. Signature of Medical Provider. Date

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