STATE OF ALASKA - DIVISION OF MOTOR VEHICLES
APPLICATION FOR DISABLED PARKING IDENTIFICATION
PART 1. TO BE COMPLETED BY APPLICANT (APPLICANT MUST BE THE PERSON NAMED AS “PATIENT” IN PART 2.)
PRINTED NAME
MAILING ADDRESS
CITY / STATE / ZIP
TELEPHONE
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SEX
M
DRIVER LICENSE NUMBER
STATE
F
PART 2. TO BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT, NURSE PRACTITIONER, PODIATRIST or CHIROPRACTOR
To be eligible for disability parking identification the applicant must meet one or more of the definition(s) of a “person with a disability” described below. Check which
definition(s) the applicant meets. A new application is required when a customer needs a temporary permit beyond six months; or beyond the temporary duration
shown below.
1.
2.
3.
4.
5.
6.
The applicant cannot walk two hundred feet without stopping to rest.
The applicant cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive
device.
The applicant is restricted by lung disease to such an extent that their 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.
The applicant uses portable oxygen.
The applicant has a cardiac condition to the extent that their functional limitations are classified in severity as Class III or Class IV according to standards set
by the American Heart Association.
The applicant is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.
NAME OF PATIENT:
THIS DISABILITY IS:
PERMANENT
TEMPORARY - Starting Date
(Maximum 6 months)
Ending Date _____________________
mo/yr
mo/yr
I certify, by my signature as an Alaskan licensed physician, physician assistant, nurse practitioner, podiatrist or chiropractor, that the applicant meets the definition(s)
I have checked above and is entitled to disability parking identification.
Physician
PA
AUTHORIZED SIGNATURE
Nurse Practitioner
TITLE (CIRCLE ONE)
PRINTED NAME & OCCUPATIONAL LICENSE NUMBER
CITY & ZIP CODE
Podiatrist
Chiropractor
DATE
TELEPHONE NUMBER
PART 3. DMV USE ONLY
† VISITOR/TOURIST
NEW PERMIT OR PLATE #
Form 861 (Rev. 11/2007)
† PERMANENT
† TEMPORARY
† ORGANIZATION
† REPLACEMENT - PREVIOUS PERMIT / PLATE
BATCH
OFFICE
AMVC
www.Alaska.gov/dmv
DATE
/
#
/ 20
A Message from DMV
Individual customers to whom the DMV issues “disability” plates or placards
must understand their obligation to the entire community. Allowing anyone
else to use the privileges that accompany these plates or placards is a citable
offense which may result in immediate revocation of the privileges. More
importantly, such abuses deny parking spaces to those individuals who
experience a disability.
By accepting a placard or plates with parking privileges, you accept the
responsibility to use them for their intended purpose. If you loan a placard to
someone else, or allow another driver to park your vehicle in a parking space
reserved for individuals who experience a disability, you are denying your
neighbors the access they need and deserve. Please respect the needs of
others, and make sure our friends and family members understand that mobility
cannot be taken for granted.
If you are granted the privilege of parking closer to your destination, don’t
take the matter lightly. Know the rules and obey them. Thank you.
Placard or Plates?
If you are experiencing a temporary disability, you are eligible to obtain a
placard that allows you to park in designated parking spaces. For a permanent
disability, you may obtain a placard and are also eligible to obtain disability
license plates. Registration and taxes are waived for your first set of plates. All
fees are required for second or subsequent requests for disability license
plates.
Who Is Eligible?
Parking placards are available for individuals with a temporary or
permanent disability. License plates are available for individuals with a
permanent disability who:
•
•
What Is Required To Apply?
You must complete an application for disabled parking identification (Form
861), Part 1, available at all DMV locations or on the Internet at Alaska.gov/dmv.
A licensed physician, physician’s assistant, nurse practitioner, podiatrist or
chiropractor must complete Part 2 of the form, certifying that you experience
one of the qualifying disabilities. Please check the form to be sure it is
completed in full before you leave the health practitioner’s office, as incomplete
forms cannot be accepted.
•
•
•
What Are The Penalties For Misuse?
Law enforcement officers may enforce disability parking restrictions in public
or private lots that indicate the restriction by reserved parking signs or blue
painted curbs. Any citizen or property owner may request such enforcement.
Violators are subject to a fine of up to $500.00, along with having the placard or
plates confiscated.
DMV may cancel the disability parking placard or plates of any person or
organization that uses them improperly.
Where Do I Hang The Placard?
Hang the placard from your rear view mirror when parked in a space
designated for use only by individuals who experience a disability. Be sure to
remove the placard from your rear view mirror before driving the vehicle, as it
can obstruct your vision.
When Does The Placard Expire?
Permanent placards are issued for up to 5 years. Temporary placards are
issued for a maximum of 6 months. The expiration date is printed on the
placard. The placard expires on the last day of the month shown on the
placard.
•
Cannot walk 200 feet without stopping to rest.
Cannot walk without the use of, or assistance from, a brace, cane, crutch,
another person, prosthetic device, wheelchair, or other assistive device.
Are restricted by lung disease to such an extent that their 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.
Use portable oxygen.
Have a cardiac condition to the extent that their functional limitations are
classified in severity as Class III or Class IV according to standards set by
the American Heart Association.
Are severely limited in their ability to walk due to an arthritic, neurological,
or orthopedic condition.
Who Can Use The Placard/Plates?
State law requires that the authorized holder (person with the disability) must
enter or exit the vehicle when parking in a space reserved for individuals who
experience a disability. In other words, if you experience a disability and have
been issued a placard or plates, you may not park in a reserved parking space
and stay in the vehicle while another person who is not disabled or mobility
impaired runs an errand.
Using a placard or plate that was issued to another person could result in a
fine of up to $500.00. Loaning a placard to another person can result in your
privileges being revoked.
(907) 269-5551
Form 861 (Rev. 11/2007)
www.Alaska.gov/dmv