PERSON WITH A DISABILITY PARKING PERMIT APPLICATION

FORM PA-1 SIDE 1 January 2018

FIRST TIME, TEMPORARY & REPLACEMENT PLACARDS

STATE OF HAWAII

DISABILITY AND COMMUNICATION ACCESS BOARD

This form must be taken to a County issuing site. Applicant must

present proof of identity. All forms of identification (ID) shall be current or

valid. Acceptable forms of ID include: driver’s license, state ID, passport,

senior citizen ID, ID of a parent or guardian of a minor, Medicare card; notarized affidavit

from: a Hawaii State or county social service agency, the administrator of a Hawaii

State or privately owned nursing home, the spouse, an adult relative, a friend, an

assistant, the verifying physician or verifying advanced practice registered nurse.

If submitting this form on behalf of the applicant (see item #15), the applicant’s

ID or a legible copy must be presented to the issuing agency! The authorized

representative appearing must also present his/her own proof of ID to the issuing agency.

1. APPLICANT’S NAME ________________________________________________________________________________

Last

___________________________________________________ _________

First MI

2. PHONE NUMBER ______________________________ 2a. EMAIL ______________________________________

(xxx) xxx-xxxx Optional

3. BIRTH DATE ________________ 4. HEIGHT __________ 5. WEIGHT _________ 6. GENDER Male Female

mm/dd/year Feet, Inches Pounds

7. RESERVED.

8. MAILING ADDRESS _____________________________________________________________________ ____________

Street Apt #

_______________________________ ________________________ _______________________

City State Zip Code

9. INDICATE THE COUNTY WHERE YOU LIVE

City & County of Honolulu County of Hawaii County of Kauai County of Maui

10. PARKING PLACARD REQUEST (Switching from a temporary placard to a long term placard is considered a first time application)

Mark applicable box and enter serial number of placard(s) already issued. I am requesting a:

First Time temporary or long term placard

Second temporary placard

Renewal of my Hawaii temporary placard(s) placard #(s) ____________________ /_______________________

Replacement of my Hawaii placard(s) placard #(s) ____________________ /_______________________

11. COMPLETE ONLY IF REQUESTING SPECIAL LICENSE PLATES

I am interested in receiving information on how to apply for special license plates at the County issuing site.

I am requesting special license plates. I am the registered owner of the vehicle on which the special license plates

will be affixed, AND the vehicle will be used primarily to transport me.

Year of Vehicle ______________ Make __________________________ Model ______________________________

Vehicle Lic. # _______________ Vehicle Registration Expiration Date _________________________________

mm/dd/year

FOR OFFICIAL USE ONLY

Placard # _______________

Expiration Date _____________

License Plates # ____________

FEES COLLECTED, IF APPLICABLE

Amount Collected $ __________

X_______________ ___________

Clerk’s Initials Date

12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I declare, under the penalties of the penal law, that the statements contained herein are, to the best of my knowledge and belief, true

and accurate, and that I have not knowingly and willingly made a false statement or given information which I know to be false in

connection therewith. I also authorize my physician or advanced practice registered nurse to release medical information necessary

to process this application.

APPLICANT’S SIGNATURE (or Authorized Representative) Date

FORM PA-1 SIDE 2 January 2018

CERTIFICATION BY LICENSED PRACTICING PHYSICIAN/APRN

This page must be completed by a licensed practicing physician (as defined under Hawaii Revised Statutes (HRS) §§453, 455, 460,

or 463E) or an advanced practice registered nurse (as defined under HRS §457).

CERTIFICATION OF CONDITION: The physician or advanced practice registered nurse (APRN) must certify that the applicant (1)

has a disability that limits or impairs the ability to walk and (2) has one or more of the specific conditions listed under item 13 below

(as defined under HRS §291-51). Individuals who belong to any of the following classes do not qualify for a permit based solely on

that status: persons who have a visual impairment; persons who have a mental illness; persons who are old; persons who are infants;

persons who are deaf; persons who have an upper limb amputation; persons who are pregnant; and persons who have a behavioral,

learning, intellectual, or developmental disability.

13. I certify that ____________________________________________ has a disability that limits or impairs the ability to walk and

Applicant’s Name

(a) CANNOT WALK (under his/her own power) 200 feet without stopping to rest due to the following condition:

Arthritic Neurological Orthopedic Oncologic Renal Vascular

(b) Is diagnosed with the following RESPIRATORY DISABILITY:

FEV < 1L – Forced (respiratory) expiratory volume for one second, when measured by spirometry, is less

than one liter.

< 60 mm. Hg – Arterial oxygen tension is less than sixty mm/hg on room air at rest.

Class III – Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at

rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.

Class IV – Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.

Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any

physical activity is undertaken, discomfort is increased.

(d) CANNOT WALK (under his/her own power) without the use of, or assistance from, the following:

Artificial Lower Limb(s) Brace(s) Crutches Walker Cane(s) (excluding white canes)

Another Person Wheelchair Other Assistive Device (specify): ________________________

(e) USES PORTABLE OXYGEN.

14. DURATION OF DISABILITY:

Mark one box only. If the disability lasts longer than anticipated, subsequent certification can be made.

1 month 2 months 3 months 4 months 5 months 6 months

6 years (only check if disability is expected to last a minimum of 6 years)

15. APPLICANT IS UNABLE TO APPLY IN PERSON (Mark only if applicable)

I certify that this applicant is physically unable to apply in person due to a medical condition. _________________________

Physician’s/APRN’s Signature

SSignatureSignature

FOR PROCESSING SUBMIT COMPLETED FORM TO APPROPRIATE COUNTY ISSUING AGENCY.

For more information or the locations of county issuing sites visit http://health.hawaii.gov/dcab/ or call (808) 586-8121.

16. PHYSICIAN/APRN CERTIFICATION. I understand that per HRS §291-51.4, a physician/APRN, who fraudulently verifies that the

applicant is qualified for purposes of this form shall be guilty of a petty misdemeanor and each fraudulent verification shall constitute

a separate offense. DCAB conducts random checks to verify the authenticity of certifications.

a. PHYSICIAN’S/APRN’S NAME ______________________________ __________________________________ _____

Print or Type Last First MI

b. MAILING ADDRESS ________________________________________ ___________________________ HI 96__________

Print or Type Street/PO Box City Zip Code

c. PHONE NUMBER (808) _________________________________

d. PHYSICIAN’S/APRN’S SIGNATURE x ____________________________________

MEDICAL LIC. NO. M.D. / N.D. / D.O. / D.P.M. / APRN # __________________________________

(circle one) Hawaii or U.S. Armed Services Stationed in Hawaii

e. DATE __________ /____________/____________

Month Day Year

Form PA-1 Instruction Sheet

First Time, Temporary, and Replacement Placards; and Special License Plates Applications

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PERSON WITH A DISABILITY PARKING PERMIT APPLICATION FORM

INSTRUCTION SHEET

Use Form PA-1 to apply for

First Time, Temporary, and Replacement Placards; and Special License Plates

SIDE 1 – TO BE COMPLETED BY APPLICANT

1. APPLICANT’S NAME. Print or type your name, beginning with your last name, then first name, and then middle

itial.

2. PHONE NUMBER. Print your telephone number. If you do not have a telephone number, write “NONE.”

2a. EMAIL. Enter your email address if you have one. This is optional. DCAB will use it ONLY to contact you for

parking program purposes.

3. BIRTH DATE. Print the month, then day, then year. Example: If your date of birth is June 30, 1965, you would

int 06/30/1965.

4. HEIGHT. Print your height in feet and inches.

5. WEIGHT. Print your weight in pounds.

6. GENDER. Mark the box for either Male or Female.

7. RESERVED.

8. MAILING ADDRESS. Print your mailing address.

9. INDICATE THE COUNTY WHERE YOU LIVE. Answer only if you live in Hawaii. Mark the box next to the

ounty in which you live. Mark one box only.

10. PARKING PLACARD REQUEST. Mark the box next to the type of placard you are requesting.

• A First Time placard. Mark this box if this is the first time that you are applying for a Long-term (blue i

color) or Temporary (red in color) placard. A Temporary placard will be valid for no more than 6 months.

There is a $12 fee for a Temporary placard.

• A Second Temporary placard. Mark this box if you would like a Second Temporary (red in color)

placard. A second Temporary placard is an additional placard that has the same expiration date as its

companion placard. If you already have a Temporary placard, print its serial number in the space

ovided. Check your ID card for the Temporary placard number. There is a $12 fee for a Sec

ond

emporary placard.

• A Renewal of a temporary placard(s). Mark this box if you want to renew your Temporary (red in color)

placard(s). You may apply up to 60 days before it expires. Print the serial number of your expiring or

expired Temporary placard(s) in the space provided. Check your ID card for your placard number(s). If

you currently have two Temporary placards and want two renewal Temporary placards, make sure t

ent

er the serial number of each expiring or expired placard in the space provided. YOU MUST ALS

VE YOUR DISABILITY RECERTIFIED BY A LICENSED PRACTICING PHYSICIAN/ADVANCED

PRACTICE REGISTERED NURSE (APRN). There is a $12 fee for each Temporary placard issued.

• A Replacement of a (Lost, Stolen, Mutilated or Confiscated) placard(s). Mark this box if your placar

as lost, stolen, mutilated or confiscated. Print the serial number(s) of your placard(s) in the spac

ovided. Check your ID card for the placard number(s). There is a $12 fee for the replacement of a lost,

stolen or confiscated placard. There is no fee for the replacement of a mutilated placard, but you must

bring in its remaining parts, otherwise, it will be treated as a replacement of a lost placard and a $12 fee

will be charged.

11. SPECIAL LICENSE PLATES REQUEST. Mark only if requesting special license plates. You must provide

nformation where indicated. You may obtain one set of plates and one long term placard.

12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION. Read the information

arefully. This is your statement that you understand the terms of using the placard or special license plates.

Sign and date the statement. If you are unable to sign due to your disability, your authorized representative may

sign on your behalf.

Form PA-1 Instruction Sheet

First Time, Temporary, and Replacement Placards; and Special License Plates Applications

2 of 2

SIDE 2 – TO BE COMPLETED BY A PHYSICIAN OR ADVANCED PRACTICE REGISTERED NURSE

ONLY IF SIDE 1 IS COMPLETED FIRST

13. CRITERIA. Mark one or more of the qualifying conditions. The following conditions do not qualify: blindness;

deafness; upper limb amputation; mental illness; old age; pregnancy; infancy; behavioral, learning, intellectual or

dev

elopmental disabilities.

14. DURATION OF DISABILITY. Mark the box that corresponds to the expected duration of the qualifying

isability. If the expected duration is less than six years, mark the box next to the month of the expecte

dur

ation. Subsequent certifications can be made if the disability lasts longer than six months. If the disability is

expected to last a minimum of six years, mark the 6 years box.

15. UNABLE TO APPLY IN PERSON. Mark if the applicant is unable to apply in person due to a medical condition.

16. PHYSICIAN / APRN SIGNATURE AND CERTIFICATION. Input the following information:

a) Physician/APRN name.

b) Physician/APRN mailing address.

c) Physician/APRN phone number.

d) Physician/APRN signature (digital signature is acceptable).

Circle medical license type (only listed types are accepted).

Input medical license number (must be a Hawaii license unless military stationed in Hawaii).

e) Date that the Physician/APRN signs the application.

_____________________________________________________________________________________________

WHERE TO SUBMIT THE COMPLETED APPLICATION

For all Form PA-1 – First Time, Temporary, and Replacement Placards; and Special License Plates

Applications.

Applicant must submit the form in person at a county issuing site unless his or her Physician/APRN has certified the

applicant is unable to appear in person because of a medical condition (see item#15). A person appearing on behalf

of an applicant must present the applicant's ID or a legilble copy along with the completed application form.