Disabled Parking Permit Application - SAAQ

1 First nameFirst nameRelation to Disabled personLast nameLast name1 - To get around, are you required to use a wheelchair or adapted stroller that is subsidized by the R gie de l assurance maladie du Qu bec (RAMQ)? 2 - If you hold a driver s licence, does it bear Condition P? A Information on Disabled personB Information for Permit eligibilityC Assessment (where required, this section must be filled out by the assessment professional identified in Section D )Telephone (work)Telephone (work)Telephone (home)Telephone (home)Address (Number, street, apartment) Disabled person s representative (if applicable)MunicipalityDriver s licence number (if applicable)ProvincePostal codeSexFemaleMaleCorrespondenceEnglishFr enchClaim file number: If you are applying for a Disabled Parking Permit because of a disability resulting from a road accident, check the box below and provide the information note Information provided on this Application may be used in assessing the subject s fitness to drive a motor vehicle.

2 The SAAQ does not reimburse the fees that may be charged by an assessment of birth Year Month DayI authorize the SAAQ to consult my claim file in order to assess whether I am eligible to receive a Disabled Parking Permit at no Proof of subsidy from the RAMQ must be enclosed. Proceed directly to Section E .Ye s Proceed directly to Section E . If you cannot enclose proof of subsidy, proceed to the following Proceed to the following Have Section C filled out by a recognized assessment professional. Date of the accident: Year Month DayFather/MotherCuratorSpouseTrusteeOthe r, specify: DCEE1 - Under the Highway Safety Code, a driver may stop his vehicle in a location where stopping is not usually permitted to take on or let out a Disabled person. Can the person be left alone without risk to his/her health and safety?

3 2 - Give diagnoses, impairments, stages, prognoses, congenital or acquired causes, etc. 3 - If one of the person s organ systems listed below is impaired, please check the system affected and circle the functional class: 4 - Check disability: 5 - Is the disability permanent or temporary? 6 - Specify loss of autonomy during outdoor movement. Motor activity (balance, walking, etc.)VisionMental activity (awareness, spatial orientation, judgment, etc.)Behaviour (personal safety, impulse control, etc.)Ye sNoOther, specify: Respiratory I II III IV V (according to the Medical Research Council)Cardiac I II III IV (according to the New York Heart Association)HearingPermanentTe m p or ar ystart: Year Month Dayprobable end: Year Month Day6375A 30 (2022-12) Disabled Parking Permit ApplicationOriginal document in FrenchSoci t de l assurance automobile du Qu becPage 1 of 2I, the undersigned, hereby authorize the Soci t de l assurance automobile du Qu bec to exchange information on my state of health and my handicap situation with the assessment professional identified in Section D or my representative identified in Section A.

4 Where required. I understand that a summary of all communications will be recorded in my addition, I declare that the information provided is correct. Enclose a cheque or money order made payable to the Soci t de l assurance automobile du Qu bec. For information regarding fees, please visit The fee is not refundable. Allow 4 to 6 weeks for processing of the Application and notification of a decision by Information on assessment professionalE Disabled person s signatureSignatureDate (Year-Month-Day)Vignette de stationnement pour personnes handicap es (act. 6630) Soci t de l assurance automobile du Qu bec Case postale 19850, succursale Terminus Qu bec (Qu bec) G1K 8Z4 Toll-free: 1-800-361-7620 (Qu bec, Canada, United States) Website : / TTY Toll-free in Qu bec: 1-800-565-7763 Ann e Mois JourRSCINDEMPTR SERV LA SOCI T Last and first nameInformation on Disabled personDriver s licence number (if applicable)C Assessment (continued)7 - What mobility aids does the person use to move about outdoors?

5 8 - Over what distance can the person move about? 9 - Can the person move about outdoors without risk of illness, trauma or to the integrity of one of the organ systems? Additional comments: Ye sNoUnassistedWith human helpTechnical aids (cane, wheelchair, etc.), specify: UnassistedAssisted (technical or human help)50 metres or less50 metres or lessMore than 50 metresMore than 50 metresDate of assessment: Year Month DayDate of report: Year Month DayFirst nameLast nameTelephoneProfession codeProfessional licence numberSignatureES Special educator of the health and social services networkER Occupational therapistIN NurseMD PhysicianOP OptometristPH PhysiotherapistPS PsychologistADProtection of Personal InformationThe SAAQ only collects personal information that is necessary for it to exercise its powers and apply the laws it administers.

6 All personal information gathered by authorized personnel is handled confidentially. This information may be shared with our licensing agents and certain government departments or agencies, including those located outside Qu bec, in accordance with the Act respecting Access to documents held by public bodies and the Protection of personal information. It may also be used for statistical, survey, study, audit or investigative purposes. Failure to provide this information can result in a refusal of service. You may consult, correct or obtain a copy of any personal information concerning you. For more information, consult the Policy on Privacy on the SAAQ s website at or contact the SAAQ s call 30 (2022-12)If you are unable to print this form, send an email to and we will mail you a document in FrenchSoci t de l assurance automobile du Qu becPage 2 of 2