PERMANENT DISABILITY by wxv15919

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									FEE $5 .00 EACH               North Carolina Division of Motor Vehicles                                  FEE $5 .00 EACH               North Carolina Division of Motor Vehicles
    (limit 2)               3148 Mail Service Center, Raleigh, NC 27699           _____________              (limit 2)               3148 Mail Service Center, Raleigh, NC 27699           _____________
                                                                                      DATE ISSUED                                                                                              DATE ISSUED
                        APPLICATION FOR HANDICAPPED PLACARD                                                                      APPLICATION FOR HANDICAPPED PLACARD
                             FOR PERMANENT DISABILITY                             _____________                                       FOR PERMANENT DISABILITY                             _____________
                                                                                     DATE EXPIRED                                                                                             DATE EXPIRED
                               REGISTRATION CARD                                                                                        REGISTRATION CARD
                           PLACARD NUMBER                                 LICENSE FEE COLLECTED                                     PLACARD NUMBER                                 LICENSE FEE COLLECTED

                                                                      $                                                                                                        $
   I hereby certify that the physical condition of the below named applicant constitutes a handicapped      I hereby certify that the physical condition of the below named applicant constitutes a handicapped
person as defined under statutory provision G S. 20-37.5.                                                person as defined under statutory provision G S. 20-37.5.
DRIVER LICENSE #                                      APPLICANT’S NAME                                   DRIVER LICENSE #                                      APPLICANT’S NAME




STREET OR RFD AND BOX NUMBER                                                                             STREET OR RFD AND BOX NUMBER



CITY                           STATE                    ZIP CODE                      COUNTY             CITY                           STATE                    ZIP CODE                      COUNTY



PHONE NUMBER                                                                VALIDATION                   PHONE NUMBER                                                                VALIDATION



APPLICANT’S SIGNATURE                                                                                    APPLICANT’S SIGNATURE


PHYSICIAN’S SIGNATURE                                                                                    PHYSICIAN’S SIGNATURE



PHYSICIAN’S PRINTED NAME                                                                                 PHYSICIAN’S PRINTED NAME



PHYSICIAN’S ADDRESS                                                                                      PHYSICIAN’S ADDRESS



PHYSICIAN’S PHONE NO                                 BRANCH NUMBER                                       PHYSICIAN’S PHONE NO                                 BRANCH NUMBER



AGENT                                                DATE                                                AGENT                                                DATE



MVR-37A (Rev. 05/07)                                                                                     MVR-37A (Rev. 05/07)
MVR-37 A (Reverse)                                                                                       MVR-37 A (Reverse)


     G.S. 20-37.5 Handicapped—definitions and parking privileges. (1) “Handicapped” shall                     G.S. 20-37.5 Handicapped—definitions and parking privileges. (1) “Handicapped” shall
mean a person with a mobility impairment who, as determined by a licensed physician; (a)                 mean a person with a mobility impairment who, as determined by a licensed physician; (a)
Cannot walk 200 feet without stopping to rest; (b) Cannot walk without the use of, or assistance         Cannot walk 200 feet without stopping to rest; (b) Cannot walk without the use of, or assistance
from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive           from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive
device; (c) Is restricted by lung disease to such an extent that the person’s forced (respiratory)       device; (c) Is restricted by lung disease to such an extent that the person’s forced (respiratory)
expiratory volume of one second, when measured by spirometry, is less than one liter, or the             expiratory volume of one 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; (d) Uses portable oxygen; (e)         arterial oxygen tension is less than 60 mm/hg on room air at rest; (d) Uses portable oxygen; (e)
Has a cardiac condition to the extent that the person’s functional limitations are classified in         Has a cardiac condition to the extent that the person’s functional limitations are classified in
severity as Class lIl or Class IV according to standards set by the American Heart Association;          severity as Class lIl or Class IV according to standards set by the American Heart Association;
(f) Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic con-   (f) Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic con-
dition; or (g) Is totally blind or whose vision with glasses is so defective as to prevent the per-      dition; or (g) Is totally blind or whose vision with glasses is so defective as to prevent the per-
formance of ordinary activity for which eyesight is essential, as certified by a licensed ophthal-       formance of ordinary activity for which eyesight is essential, as certified by a licensed ophthal-
mologist, optometrist, or the Division of Services for the Blind.                                        mologist, optometrist, or the Division of Services for the Blind.
    Any person who falls within the definition of handicapped shall be allowed to park for unlim-            Any person who falls within the definition of handicapped shall be allowed to park for unlim-
ited periods in parking zones restricted as to length of time parking is permitted. This provision       ited periods in parking zones restricted as to length of time parking is permitted. This provision
has no application to those zones or during times in which the stopping, parking, or standing of         has no application to those zones or during times in which the stopping, parking, or standing of
all vehicles is prohibited or which are reserved for special types of vehicles. As a condition to        all vehicles is prohibited or which are reserved for special types of vehicles. As a condition to
this privilege the vehicle shall display a distinguishing license plate or removable windshield          this privilege the vehicle shall display a distinguishing license plate or removable windshield
placard.                                                                                                 placard.
    This placard is to be used only for transporting the handicapped to whom issued. It is to be             This placard is to be used only for transporting the handicapped to whom issued. It is to be
displayed inside the vehicle from the rearview mirror. The placard cannot be used as a sub-              displayed inside the vehicle from the rearview mirror. The placard cannot be used as a sub-
stitute license plate.                                                                                   stitute license plate.
   The person on the face of the application qualifies for the following conditions:                        The person on the face of the application qualifies for the following conditions:
   Cannot walk 200 feet without stopping to rest.                                                           Cannot walk 200 feet without stopping to rest.
   Cannot walk without use or assistance from a brace, cane, crutch, another person,                        Cannot walk without use or assistance from a brace, cane, crutch, another person,
   wheelchair, prosthetic device or other assistive device.                                                 wheelchair, prosthetic device or other assistive device.
   Is restricted by lung disease.                                                                           Is restricted by lung disease.
   Uses portable oxygen.                                                                                    Uses portable oxygen.
   Has a cardiac condition.                                                                                 Has a cardiac condition.
   Is severely limited in their ability to walk due to an arthritic, neurological or orthopedic             Is severely limited in their ability to walk due to an arthritic, neurological or orthopedic
   condition.                                                                                               condition.
   Is totally blind or whose vision with glasses is so defective as to prevent the performance of           Is totally blind or whose vision with glasses is so defective as to prevent the performance of
   ordinary activity for which eyesight is essential.                                                       ordinary activity for which eyesight is essential.

								
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