Disability License Plates and Placards

1 ITD 3392 (Rev. 08-19). Disability License Plates and Placards Supply # 019580141. Do Not Send Money With This Application. You will be billed for your fees or you may authorize payment with your credit card in the payment section at the bottom. Credit card purchases are subject to an ITD service fee. Applicant's Last Name First Name Middle Date of Birth Physical Idaho Address City State Zip Mailing Address (if different from above) City State Zip Daytime Phone Number (8:30 to 4:30 ) Qualifying Applicant's Idaho-Issued Driver License , Identification Card Number, or SSN. Additional Vehicle Owner's Last Name First Name Middle Driver's License No.

2 , SSN, or EIN. As a qualified medical professional I certify that my patient meets one of the following per Idaho Code 49-117: Unable to walk two hundred (200) feet or more without the aid of another person, a walker, cane, crutches, braces, prosthetic device, or wheelchair OR. Unable to walk two hundred (200) feet or more without great difficulty due to the following impairments: neurological, orthopedic, respiratory, cardiac, arthritic, blindness, or the loss of function or absence of a limb or limbs. Medical Certification This section must be completed and signed by a licensed physician, a licensed physician's assistant, or by a licensed advanced-practice professional nurse.

3 (Please check appropriate box and Print clearly.). Temporary Disability until .No more than six (6) months. Give specific date of expiration. Temporary Placards are issued for a period of one to six months. Permanent Disability Printed Name of Medical Professional Certifying Eligibility (Print Address Legibly). City, State, Zip Code Practitioners National Provider Identifier Office Phone Number Authorized Signature Date (required). ( ) - Permanent Card No Charge One Card Two Cards Personalized Disability License Plates Temporary Card No Charge (limit of 1) Standard Disability License Plates Fill out only if you are applying for License Plates .

4 Vehicle information section : Current Idaho License Plate Number Expiration Date Vehicle Identification Number (VIN) Motorcycle cc (if applicable). Idaho Title Number Vehicle Year Make Body Type Model Color Complete this section for vehicles over 8,000 lbs. GVW only Combined Gross Vehicle Check the appropriate category below. Weight Hazardous Material Carrier (Subject to Commercial Vehicle Non-commercial Vehicle Motor Carrier INS fee). Personalized Plates Only . Enter your plate choice below. Text must have at least one alpha character and no punctuation marks. Motorcycles are limited to four characters, all others limited to five.

5 You must include a meaning. Leave a blank square where you want a space. Extra $ initial fee. First Choice Second Choice Third Choice 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5. Meaning Meaning Meaning Check here if purchasing Idaho State Parks Passport Extra $ for 1 Year Extra $ for 2 Years Do Not Send Money! You will be billed for your fees or you may authorize payment with your credit card Credit Card Number Expiration Date Authorized Signature All credit card transactions are subject to a 3% Access Idaho service fee. Plate and placard Use: Fraudulent Application for a A motor vehicle displaying a special License plate or Plate or placard placard issued by Idaho or any other state for a person Section 49-456, Idaho Code, makes it unlawful to use with a Disability is subject to all Idaho motor vehicle a false or fictitious name or address in any application laws and is granted the following privileges when the for the registration of any vehicle or for any renewal or person with the Disability is present.

6 Duplicate, or knowingly to make false statement or conceal a material fact or otherwise commit a fraud in 1. Authorization to park in any public parking space any application.. with metered parking without being required to pay any parking meter fee. How to Apply 2. Authorization to park for unlimited periods of time for Plates or Placards in parking zones or areas which are otherwise 1. Read the use provisions and eligibility section. restricted as to the length of time parking is 2. Complete the application print clearly. permitted. 3. Have your physician complete and sign the 3. Special parking privileges do not apply to those eligibility section.

7 Zones or areas in which the stopping, parking , or standing of all vehicles is prohibited or which are All applications with a plate option selected must be reserved for special types of vehicles; to areas where mailed to: vehicular parking is prohibited for periods in excess Idaho Transportation Department of forty-eight (48) hours; or to areas where parking Vehicle Services Special Plates is prohibited for certain periods of time in order to allow snow removal, street construction or main- tenance, or for other emergency purposes. PO Box 7129, Boise, ID 83707-1129. or fax applications to: (208) 334-8542 Persons 4.

8 Access to fuel from a full-service pump at the same price as fuel from a self-service pump. This applies to locations where fuel is sold at retail from both placard only applications can be mailed to the above address or you may go to your local county DMV. With Disabilities pumps (retailers are required only to pump fuel, no You can obtain additional application forms via the other services are included in the law.) Internet at: 5. Self-serve gas stations pump gas when a disabled person with a Disability plate or placard requests If you have any questions about special Plates or assistance if there is no able-bodied adult in the Placards for persons with disabilities, please write the vehicle and there is more than one attendant at the gas station.

9 Special window signs will be posted at address above, or call (208) 334-8655. License Plate and the gas station. Personalized Disability Special placard Unauthorized Plate or License Plates placard Use Personalized Disability Plates have an extra $ initial fee and extra $ renewal fee. You must Application Section 49-410(9), Idaho Code states: Any use of the provide a meaning for each personalized plate choice. plate or placard by any person other than those meeting All personalized Disability License Plates must be the definition of Disability under section 49-117(7)(b), renewed before expiration date.

10 There is no grace Idaho Code, to obtain parking shall constitute an period. infraction punishable by a fine of one hundred dollars ($ ). The message, in any language, may not carry a sexual term that is vulgar, obscene, or in poor taste, nor consist Part of Section 49-410(10), Idaho Code states: Law of a term that is considered to be one of obscenity, enforcement officials and/or their designees as contempt, prejudice, hostility, insult, racial degradation, authorized by a city or county shall enforce the ethnic degradation, profanity, or vulgarity. provisions of this section and are empowered, using ITD 3392 (Rev.)