APPLICATION FOR A DISABILITY LICENSE PLATE (BRANCH USE ONLY) DISABILITY STICKER ONLY Instructions: Applicants please complete and sign Part 1. Your physician, chiropractor, optometrist, nurse practitioner or physician’s assistant must complete Part 2 and the certification on the back of this page. Applications cannot be processed without a signed release of information and a licensed physician, chiropractor, optometrist, nurse practitioner or physician’s assistant’s certification. Completed applications may be presented at any Secretary of State office or mailed to the address on the reverse side. (Keep a copy of your submitted application for your records.) A vehicle used to transport a permanently disabled person may qualify for a disability license plate when the vehicle owner resides at the same address as the permanently disabled person. The plate may be issued for passenger type vehicles, pickup trucks, and vans. Commercial vehicles and trailers are not eligible. A physician’s certification is not needed if the applicant has a permanent disability parking permit, which is not expired, or another disability plate in his or her name. Enter the parking permit number and its expiration date or the disability plate number. Permanent Disability Parking Permit or Disability Plate Number: _______________________ Expiration Date: ___________________________ Part 1: Release of Information and Signature I am applying for a disability parking license plate as provided in Public Act 300 of 1949. I authorize the release of the medical information described below to the Michigan Department of State. I certify the information is true and realize by making a false statement on this application, I am subject to the penalties described on the reverse side. Vehicle Owner’s Name Driver’s License Number or Personal ID Number Street Address Daytime Phone Number ( ) City Name of Permanently Disabled Person if Other Than Vehicle Owner (Must Reside at Same Address) Year State ZIP County Vehicle Information Driver’s License or State ID Card Number (If None, State Age of Individual) Make Body Style Vehicle Identification Number I own a van and use a wheelchair, and I am eligible for this disability license plate at half fee (vans only). I own a van and transport a member of my household who uses a wheelchair, and I am eligible for this disability license plate at half fee (vans only). I wish to cancel the current license plate on my vehicle as credit toward the disability license plate. Plate Number: _______________________________ Expiration Date: __________________________________ (Your current plate will not be cancelled until after you receive your new disability plate.) Please allow two weeks for delivery. License plate is not renewable when the person with the disability no longer resides in the household or is deceased. I certify all the information is correct and I am eligible for a disability license plate. APPLICANT’S SIGNATURE X__________________________________________________ DATE _____________________________________ MV-110 (09/12) (Authority granted under Public Act 300 of 1949, as amended)
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