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APPLICATION FOR MOBILITY-IMPAIRED PARKING PERMIT ND …

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.

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 Name of Applicant (Patient) Name of Medical Provider

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