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Application For Vehicle License Plates And-Or Placard For Persons With A Disability SP-41 - New Jersey

Application For Vehicle License Plates And-Or Placard For Persons With A Disability Form. This is a New Jersey form and can be used in Motor Vehicle Commission Statewide .
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Special Plate Unit P.O. Box 015 Trenton, New Jersey 08666-0015 888-486-3339 (NJ Toll Free) 609-292-6500 (Out-of-State) STATE OF NEW JERSEY License Plate No: ______________________ Placard No: _____________________ Date Issued: __________________ Employee's Initials: ________________ (FOR COMMISSION USE ONLY: DO NOT WRITE ABOVE THIS LINE) APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARD FOR PERSONS WITH A DISABILITY THIS IS MY: INITIAL APPLICATION RECERTIFICATION APPLICATION PLACARD BOTH REPLACEMENT APPLICATION I AM APPLYING FOR: LICENSE PLATES SECTION A: PERSON WITH A DISABILITY IDENTIFICATION CARD INFORMATION Name of Person with a Disability: ____________________________________________________________________ Street Address: __________________________________________________________________________________ City, State, Zip Code: _____________________________________________________________________________ Driver's License Number: ____________________________________________ Expires _______________________ Date of Birth: __________________ Sex: ________ Eye Color: ____________Ht: _____________ Wt: ____________ I acknowledge that I hold a Commercial Driver License (CDL) and that this application may result in a medical review which could result in a decision that may affect my New Jersey CDL privilege. Current Plate Number: __________________ Current Placard Number: _________________ (for recertification applications) SECTION B: WHEELCHAIR SYMBOL LICENSE PLATES (photocopy of registration required) Registered Vehicle Owner's Name_____________________________ Vehicle Plate No._______________ Expires________ Registered Vehicle Owner's Driver License Number___________________________________ Expires _______________ Street Address________________________________________ City, State, Zip Code_____________________________ Relationship to the Disabled Applicant: Spouse Parent Guardian Self Other (Please Specify) ________________ SECTION C: REPLACEMENT PLATES, PLACARD AND/OR IDENTIFICATION CARD LICENSE PLATES PLACARD IDENTIFICATION CARD Vehicle Plate Number__________________ Expires_________ Placard Number__________________ Expires__________ Check one: Lost­ attach notarized statement of loss. Damaged ­ return (plate(s), placard and/or ID card). Stolen ­ plate(s), placard ­ attach police report. SECTION D: CERTIFICATION OF STATEMENTS I CERTIFY, UNDER PENALTY OF LAW, THAT THE STATEMENTS ON THIS APPLICATION ARE TRUE. Signature of Registered Vehicle Owner: ________________________________________________Date:___________ Signature of Person with a Disability: __________________________________________________Date: ___________ SECTION E ­ MEDICAL PRACTITIONER'S CERTIFICATION & SECTION F - TERMS AND CONDITIONS (on page 2) SP-41 (R7/13) Page | 1 of 2 American LegalNet, Inc. MUST BE COMPLETED FOR PROCESSING APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARDS FOR PERSONS WITH A DISABILITY SECTION E: MEDICAL PRACTITIONER'S CERTIFICATION Name of Medical Practitioner: ________________________________________________ Street Address: _________________________________________________ City, State, Zip Code: __________________________________________ Telephone number: _____________________ National Provider Identification Number (NPI #): ________________________________________ (required) Taxonomy Code: ____________________________________ (required) Required prescription attached. Required letterhead attached (ONLY for medical practitioners who are not authorized to write prescriptions). By law, eligibility for license plates and/or a placard for persons with a disability is limited to the following conditions. (NO OTHER PERSON IS ELIGIBLE FOR LICENSE PLATES AND/OR A PLACARD). Patient Name (print) ____________________________________________________________ 1. Has lost the use of one or more limbs as a consequence of paralysis, amputation, or other permanent disability. 2. Is severely and permanently disabled and cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assistive device. 3. Suffers from lung disease to such an extent that the applicant's forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air at rest; or uses portable oxygen. 4. Has a cardiac condition to the extent that the applicant's functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association. 5. Is severely and permanently limited in the ability to walk because of an arthritic, neurological, or orthopedic condition; or cannot walk two hundred feet without stopping to rest. 6. Has a permanent sight impairment of both eyes as certified by the N.J. Commission of the Blind (Placard only). I CERTIFY, UNDER PENALTY OF LAW, THAT MY PATIENT (print name) _________________________________________ HAS BEEN PERSONALLY EXAMINED BY ME AND MEETS THE ELIGIBILITY CRITERIA AS SPECIFIED IN ITEM NUMBER(S) ______________ (select from above) AND THUS MEETS THE REQUIREMENTS FOR THE RECEIPT OF LICENSE PLATES AND/OR A PLACARD FOR PERSONS WITH A DISABILITY. Signature of Medical Practitioner _________________________________________________________ Date______________ SECTION F: TERMS AND CONDITIONS 1. Pursuant to N.J.S.A. 2C:21-4(a), N.J.S.A. 2C:43-3, and N.J.S.A. 2C:43-6, making a false statement or providing misinformation on an application to obtain or facilitate the receipt of license plates or placards for persons with disabilities is a fourth degree crime and a person who has been convicted of this offense may be subject to pay a fine not to exceed $10,000 and a term of imprisonment of up to 18 months. 2. Wheelchair symbol license plates may be issued for one vehicle owned, operated or leased by a person with a disability or family member providing transportation for that person. 3. Wheelchair symbol license plates must be renewed every year, disability recertification is required every three years. 4. The placard must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a designated wheelchair symbol parking space and must be removed when the vehicle is in motion. 5. Persons with a Disability Identification Cards and placards must be recertified every three years. 6. The Motor Vehicle Commission requires that the disability of
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