The Oklahoma Handicapped form is an application used to request a handicapped parking placard from the Department of Public Safety. This form must be thoroughly completed by both the applicant and a licensed physician to ensure eligibility. Upon approval, the placard allows individuals with disabilities to park in designated handicapped spaces, enhancing their access to public facilities.
The Oklahoma Handicapped Parking Placard Application is a crucial document for individuals with mobility impairments, allowing them to access designated parking spaces. To initiate the process, applicants must complete the form in its entirety, ensuring that both personal information and medical verification from a licensed physician are included. This application serves not only as a request for a parking placard but also triggers a review of the applicant's ability to operate a vehicle safely. The Department of Public Safety requires approximately ten business days to process the application once submitted. A processing fee of $1.00 is applicable for each placard issued, and payment should be made via check, as cash is not accepted. The form outlines specific criteria that must be met to qualify for a placard, including various medical conditions that significantly limit mobility. Applicants must also understand the legal implications of misrepresenting their need for a placard, which can result in fines. Once approved, the placard must be displayed prominently in the vehicle, ensuring compliance with state regulations.
HANDICAPPED PARKING PLACARD APPLICATION
The Department of Public Safety requires approximately 10 business days after receipt to process the application.
NOTICE: The inform ation subm itted on this form may cause a review of your ability to operate a motor vehicle
as provided in 47 O .S. Section 6-119, pursuant to the standards prescribed by the driver license medical
advisory com m ittee as created in 47 O .S. 6-118.
THIS FORM MUST BE FULLY COMPLETED BY APPLICANT AND PHYSICIAN BEFORE A HANDICAP PLACARD CAN BE ISSUED.
THERE IS A $1.00 PROCESSING FEE FOR EACH PLACARD ISSUED. MAKE CHECK PAYABLE TO: DEPARTMENT OF PUBLIC SAFETY
PLEASE DO NOT SEND CASH.
I hereby make application to the Oklahoma Department of Public Safety for a handicapped parking placard. I understand I must display the official placard on the rearview mirror of my vehicle. I further understand this item may only be displayed in motor vehicles either operated by me, or in which I am a passenger. I further understand that any person who knowingly makes false application for or unauthorized use of a handicapped placard is guilty of a misdemeanor and upon conviction thereof shall be punished by a fine of not more than $500.00.
P LE AS E P R IN T O R TYP E
APPLICANT’S (PATIENT) NAM E:
DATE OF BIRTH:
(FIRST)
(MIDDLE)
(LAST)
M AILING ADDRESS:
(STREET OR P.O. BOX)
(CITY)
(STATE)
(ZIP)
DRIVER LICENSE NUM BER:
PHONE:
(HOME)
SIGNATURE:
TH E FO LLO W ING MUST BE C O MPLETED B Y A PERSO N LICENSED TO A PR ACTICE MEDICINE, SUR G ERY,
O STEO PAT HIC, CH IRO PRA CTIC O R PEDIATR IC MEDICINE, O R O PTO METRY . THE ABOVE NAM ED APPLICANT (PATIENT):
ο
A.CANNOT WALK TWO HUNDRED (200) FEET WITHOUT STOPPING TO REST, OR
C.IS RESTRICTED TO SUCH AN EXTENT THAT THE PERSON’S FORCED
(RESPIRATORY) EXPIRATORY VOLUME FOR ONE (1) SECOND, WHEN MEASURED BY SPIROMETRY, IS LESS THAN SIXTY (60) MM/HG ON ROOM AIR AT REST, OR
E.HAS FUNCTIONAL LIMITATIONS WHICH ARE CLASSIFIED IN SEVERITY AS CLASS
III OR CLASS IV ACCORDING TO STANDARDS SET BY THE AMERICAN HEART ASSOCIATION, OR
G.IS CERTIFIED LEGALLY BLIND, OR
B.CANNOT WALK WITHOUT THE USE OF OR ASSISTANCE FROM A BRACE, CANE,
CRUTCH, ANOTHER PERSON, PROSTHETIC DEVICE, WHEELCHAIR OR OTHER ASSISTANT DEVICE, OR
D.MUST USE PORTABLE OXYGEN, OR
F.IS SEVERELY LIMITED IN HIS OR HER ABILITY TO WALK DUE TO AN ARTHRITIC, NEUROLOGICAL, OR ORTHOPEDIC CONDITION, OR
H.IS MISSING ONE OR MORE LIMBS WHICH IMPAIRS MOBILITY.
IN YOUR PROFESSIONAL OPINION WOULD THIS CONDITION AFFECT THIS PERSON’S ABILITY TO SAFELY OPERATE A MOTOR VEHICLE UNDER NORMAL OR ADVERSE DRIVING CONDITIONS?
οNO
οYES DIAGNOSIS:
TYPE OF PLACARD REQUESTED:
TEMPORARY ISSUED
FOR UP TO 6 MONTHS
5 YR. PLACARD
TEMPORARY PLACARD
EXPIRATION DATE:
I certify that the applicant’s physical disability described above is accurate and the care and treatment is within the authorized scope of my practice.
DATE:
PHYSICIAN’S NAME:
PHYSICIAN’S LICENSE NO.
PLEASE PRINT OR TYPE
ADDRESS:
PHYSICIAN’S SIGNATURE:
FO R D PS O FFICE O N LY
Expiration D ate:
D ate issued:
Placard N umber:
M ail t h is co m p le t ed ap p licat io n w it h o n e d o llar ch e ck t o :
If you have any questions, please call (405)/425-2290
O klahom a D epartm ent of P ublic S afety
D river License Services D ivision
P .O . B ox 11415
O klahom a C ity, O K 73136 -0415
DPS: DLS0791-94 4 REV. 3 04
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