Free Apply for permanent disability ID card - Wisconsin

PERMANENT DISABILITY ID CARD APPLICATION
MV2548 5/2008 Ch. 343 Wis. Stats.

This Area for Office Use

HOW TO APPLY
1. Read the Eligibility Section and complete the Applicant Section if you qualify. 2. Have an authorized health care specialist complete the Eligibility Section. 3. You MUST keep a copy of this completed application and provide it for inspection upon request by any traffic officer. Make and keep a copy before submitting application to WI DOT. 4. Check number of cards requested. A second card is allowed if you do NOT have disabled license plates or disabled veteran license plates. 5. NO FEE is required for issuance, renewal, or replacement. However, applications made at a local DMV Service Center that provides ID card service are subject to a $3.00 counter service fee. 6. Mail application to: Wisconsin Department of Transportation Special Plates Unit - ID Clear Form PO Box 7306 Madison, WI 53707-7306

APPLICANT SECTION - Please print clearly. Check appropriate boxes.
Original - Number of Cards: 1 2 Replacement(s) Needed - Indicate Card # and reason for replacement Lost Lost
Legal Name of Person with Disability - First, Middle Initial, Last Address City, State, ZIP Code Social Security Number - For Identification Purposes Driver License/Nondriver ID Number - If none, write NONE Birth Date

Renewal of card number(s): ______________

Stolen Stolen

Mutilated / Illegible Mutilated / Illegible

Female Male

Telephone Number Where You May be Reached 7 a.m. - 4:30 p.m.

I have read the information on this form and understand the qualifications under which my Disabled Parking ID Card may be issued.

(Signature of Person with Disability) or (Person Signing on Behalf of Person with Disability) If signing on behalf of the person with a disability, give the following:

(Date)

(Name of Person Signing for Applicant - Please Print)

(Relationship to Applicant)

ELIGIBILITY SECTION
This must be completed and signed by any of the following health care specialists licensed to practice in any state: a physician, a podiatrist, an advanced practice nurse, a chiropractor, a public health nurse or physician assistant who is licensed or certified; or a Christian Science Practitioner residing in Wisconsin; or by an authorized VA representative. This statement is for issuance of a disabled
parking ID card and is not to be considered as a claim for VA benefits.

If you feel this applicant's medical condition or disability may prevent them from exercising reasonable control over a motor vehicle, please contact the Medical Review Unit at 608-266-2327 or refer to http://www.dot.wisconsin.gov/drivers/drivers/aging/impaired.htm, for the reporting process.
Name of Person Certifying Eligibility Address City, State, ZIP Code Medical License Number Area Code - Office Telephone Number

Eligibility Certification Statement - I certify that the applicant is permanently disabled according to the conditions specified
on this form.

(Authorized Signature of Health Care Specialist)

(Date)

ID CARD USE
A person who displays a Disabled Parking Identification (DIS ID) Card on their vehicle (except motorcycles and mopeds): Is exempt from any parking ordinance imposing time limits of one-half hour or more, but is otherwise subject to the laws relating to parking; Can park at a municipally-owned/leased lot without payment in metered spaces when the time limit is one-half hour or more; May park in spaces marked by official traffic signs reserving the space for vehicles displaying VET or DIS plates or DIS ID cards; Upon request, a driver who is disabled may obtain fuel from a full-service pump at the same price as fuel from a self-service pump. This applies at locations where fuel is sold at retail from both full and self-service pumps. The retailer is not required to provide any other service that is not provided to customers who use a self-service pump.

UNAUTHORIZED ID CARD USE
Any person who sells or lends a DIS ID Card to someone who is not authorized by law to use it, may be fined up to $300 and may have the card confiscated. The Department may cancel the DIS ID Card of any person who improperly uses it. Operating a motor vehicle when the DIS ID card is left hanging from the rearview mirror is prohibited. Failure to remove the card when operating the vehicle creates an obstruction to a driver's clear view through the front windshield pursuant to s.346.88(3)(b) Wis. Stats. Violators may be required to forfeit not less than $20 nor more than $100. The Department may cancel a DIS ID card which was issued as a result of fraud or error.

Parking Identification Card Application for Individuals with a PERMANENT DISABILITY

Are you eligible? RELEASE OF NONEXEMPT INFORMATION
The Wisconsin Department of Transportation uses the information on this form to issue disabled parking identification cards. Under open records laws, the Department must make nonexempt information available upon request. If you want your name withheld from mailing lists of 10 or more individuals, check yes; otherwise, check no. Yes. No. (Will remove your name from marketing lists.)

INFORMATION
Individuals with a permanent disability are issued a blue DIS ID card that must be renewed every 4 years. You MUST keep a copy of this completed application and provide it for inspection on request by any traffic officer. Make and keep a copy before submitting application to WI DOT. If you are a licensed driver, the Department will review your disability relating to your ability to exercise ordinary and reasonable control over a motor vehicle. If the certifying health care specialist recommends a re-examination, you will be required to complete a knowledge, highway signs and road test to deter mine appropriate license restrictions. DIS ID cards are valid in all 50 states and Puerto Rico.

AMERICANS WITH DISABILITIES ACT
The Wisconsin Department of Transportation complies with the Americans with Disabilities Act.

QUESTIONS
For questions about DIS ID cards:
Call: 608-266-3041
E-mail: [email protected]
Write to the address given inside.


Any person certified by an authorized health care specialist as having a PERMANENT disability is eligible for the Disabled Parking Identification Card. By legal definition, this includes any person who: Cannot walk 200 feet or more without stopping to rest; Cannot walk without the use of, or assistance from, another person or brace, cane, crutch, prosthetic device, wheelchair or other assistance device; Is restricted by lung disease to the extent that forced expiratory volume for 1 second when measured by spirometry is less than one liter or the arterial oxygen tension is less than 60 mm/hg on room air at rest; Uses portable oxygen; Has a cardiac condition to the extent that functional limitations are classified in severity as class III or IV, according to standards accepted by the American Heart Association; Is severely limited in the ability to walk due to an arthritic, neurological or orthopedic condition.
MV2548 Wisconsin Department of Transportation

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