Transcription of STATE OF ALASKA - DEPARTMENT OF ADMINISTRATION - …
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STATE OF ALASKA - DEPARTMENT OF ADMINISTRATION - …
Form 861 (Rev. 11/23/2021) STATE OF ALASKA division OF MOTOR VEHICLES APPLICATION FOR SPECIAL DISABILITY PARKING permit PART 1. TO BE COMPLETED BY APPLICANT (APPLICANT MUST BE THE PERSON NAMED AS PATIENT IN PART 2.) FULL LEGAL NAME OF APPLICANT/ PATIENT IN PART 2 (PRINTED) AK DRIVER LICENSE NUMBER OR DOB OR SSN EMAIL DAYTIME TELEPHONE NUMBER ( ) PART 2. TO BE COMPLETED BY A LICENSED ALASKAN MEDICAL PROFESSIONAL OF AN OCCUPATION LISTED BELOW NAME OF PATIENT: _____ To obtain a disability parking permit , the patient must meet one of the following requirements. Please check any that apply. 1. Cannot walk 200 feet without stopping to rest 2. Cannot walk without using a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device 3.
division of motor vehicles . application for special disability parking permit . part 1. to be completed by applicant (applicant must be the person named as “patient” in part 2.) full legal name of applicant/ patient in part 2 (printed) ak driver license number or dob or ssn email daytime telephone number ( )
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