Free 52045.FH11 - Indiana

NOTIFICATION OF ACCESSIBLE PARKING PERMIT REQUEST OR CHANGE
State Form 52045 (R / 1-07)

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DEPARTMENT OF ADMINISTRATION PARKING SERVICES 401 West Washington Street, Room 108 Indianapolis, Indiana 46204 Washington Street Facility Telephone: 232-6268 Senate Avenue Facility Telephone: 233-4635

NOTICE: In addition to this completed form, the employee must provide proof that a valid Bureau of Motor Vehicles disability license plate or disability parking placard was issued in the employees name. IDOA reserves the right to request updated information as deemed necessary. All information submitted as part of this application will be kept confidential. Instructions located on the reverse side of form.
Date (month, day, year) Name of employee (last, first, middle initial) Home address (number and street, city, state, and ZIP code) Employee has (check one): Current access tag / device number Agency Telephone number Check appropriate box:

Request for permit

Change of permit

(

)

1. 2. 3.
Year

4. terminated employment with the state. Enclosed is the access tag/device. recently been hired. Please issue an access tag/device. 5. a need for temporary accessible parking. 6.
Make Model Employee has been issued: Color

lost his/her access tag/device. Please assign another access tag/device. ($35 fee to replace device) a change in employee mobility a change in vehicle information, office location, or contact information.
Plate number Placard number State Placard expires (month, day, year)

EMPLOYEE VEHICLE INFORMATION

Vehicle has chair lift:

Left side
Building

Right side

Rear

No lift
Room number

Disability plate

Disability placard
Telephone number E-mail address

EMPLOYEE OFFICE LOCATION & CONTACT INFORMATION

(

)

TO BE COMPLETED BY EMPLOYEES PHYSICIAN
Please indicate employees mode of travel.

by foot w/ no assistance by foot w/ assistance (crutches, walker, etc.) manual wheelchair electric wheelchair Other (specify): __________________________________________________________________________________________________________
Employees condition is: If condition is temporary, please specify ending date (month, day, year)

Temporary

Permanent 1025 total distance with no noticeable incline/decline 975 total distance with the following inclines/declines 1. 10 in 12 for a distance of 80 2. 9 in 12 for a distance of 105 3. 4 in 12 for a distance of 120
Date (month, day, year) Telephone number

Please indicate employees ability (check all that apply).

500 total distance with no noticeable incline/decline 400 total distance with the following inclines/declines 1. 10 in 12 for a distance of 80 2. 9 in 12 for a distance of 105 1125 total distance with the following incline/decline 1. 4 in 12 for a distance of 120
Signature of physician Printed name of physician

(
EMPLOYEE AFFIRMATION

)

I certify that the above information is true and accurate. Falsification or misuse of accessible parking privileges may result in loss of parking privileges, towing or ticket fees, and/or discipline.
Signature of employee Date (month, day, year)

FOR OFFICE USE ONLY
Verified by BMV Garage / lot number Access tag / device number If temporary, access tag / device expiration date (month, day, year) Date (month, day, year) Title

Yes

No

Signature of approving authority Printed name of approving authority

INSTRUCTIONS FOR THE COMPLETION OF STATE FORM 52045

Please have this form completed in its entirety prior to requesting accessible parking. Incomplete applications will be returned and/or could delay the processing of your request. Please submit this completed application to: Summit Occupational Medicine 915 North Capitol Indianapolis, Indiana 46204 Or fax this completed application to (317) 631-0454. Proof of valid BMV disability plate or disability placard includes any document from the BMV that indicates that the plate or placard has been issued to the employee completing this form. Please submit this proof to: Indiana Department of Administration Parking Services 401 West Washington Street, Room 108 Indianapolis, Indiana 46204 Parking spaces will not be assigned but adequate spaces should be available in your assigned parking area. If you have trouble finding a space in your assigned area, please contact Parking Services at the number on the front of this form. If necessary, you will need to reapply for accessible parking if disability placard expires.