SP-41A (R7/13) Page 1 of 3
STATE OF NEW JERSEY
INSTRUCTIONAL CHECKLIST
APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARD FOR
PERSONS WITH A DISABILITY
PLEASE READ THESE INSTRUCTIONS CAREFULLY WHILE COMPLETING YOUR APPLICATION FORM. IF
THE APPLICATION IS NOT FULLY COMPLETED, ACCURATE AND/OR LEGIBLE IT MAY CAUSE DELAYS IN
RECEIVING YOUR PLATES AND/OR PLACARD.
CLEARLY INDICATE IF THE APPLICATION IS:
INITIAL (FIRST TIME), RECERTIFICATION OR REPLACEMENT (PROPER BOX MUST BE CHECKED).
INITIAL APPLICATION (FIRST TIME): The application process begins with the initial application, which is the same for either
license plates and/or a placard. A “Person with a Disability Identification Card” is issued with the license plates and placard. This
ID card must be carried by the person with a disability in conjunction with the use of the license plates/placard.
RECERTIFICATION APPLICATION: Medical recertification is required every three years. Persons with a disability will be
required to provide a qualified medical practitioner’s certification indicating that the qualifying medical condition still exists in
order to renew the plates and/or receive a new placard and a new Person with a Disability Identification Card.
REPLACEMENT APPLICATION: In the event that your plates and/or placard are lost, stolen or damaged, a replacement
application is required. Notarized statements may be required to obtain new plates and/or a placard depending on the circumstance.
CLEARLY INDICATE IF YOU ARE APPLYING FOR:
LICENSE PLATES, A PLACARD OR BOTH (PROPER BOX MUST BE CHECKED).
LICENSE PLATES: Wheelchair symbol license plates are renewed every year as part of the normal registration renewal process.
In order to retain the plates, a medical recertification is required every three years. However, if the holder of the “Person with a
Disability Identification Card” for whom the license plates were issued no longer qualifies for the license plates, it is the
responsibility of the owner of the vehicle to surrender the wheelchair symbol license plates and apply for a new set of regular
license plates at any MVC Agency.
PLACARD: A placard, in conjunction with the identification card, can be used in any vehicle you ride in, whether or not you own
the vehicle. The placard authorizes the driver of the vehicle to park in designated wheelchair symbol parking spaces when the
individual designated on the identification card is either driving or a passenger in the vehicle. Since the placard is transferable from
vehicle to vehicle, only one placard will be issued to each qualified applicant. There is no charge for the placard.
SECTION A: PERSON WITH A DISABILITY IDENTIFICATION CARD INFORMATION
PROVIDE APPLICANT INFORMATION FOR THE PERSON WITH A DISABILITY (DRIVER LICENSE
NUMBER, EXPIRATION DATE, DOB, SEX, EYES, HEIGHT AND WEIGHT).
COMMERCIAL DRIVER LICENSE (CDL) HOLDERS MUST ACKNOWLEDGE POSSIBLE MEDICAL REVIEW
(BOX MUST BE CHECKED).
PROVIDE PLACARD NUMBER AND/OR LICENSE PLATE NUMBER FOR RECERTIFICATION AND
REPLACEMENT APPLICATIONS.
IDENTIFICATION CARD: A “Person with a Disability Identification Card” is issued with either the license plates and/or a
placard and is valid as long as the person continues to be recertified. When using either the license plates or placard to park in
designated wheelchair symbol parking spaces, you must have your identification card with you. The ID card is non-transferable and
will be forfeited if presented by any other person.
ELIGIBILITY: Any person who has lost the use of one or more limbs, or is permanently disabled and cannot move about without
Special Plate Unit
P.O. Box 015
Trenton, New Jersey 08666-0015
888-486-3339 (NJ Toll Free)
609-292-6500 (Out-of-State)
On the Road to Excellence
www.njmvc.gov
New Jersey is an Equal Opportunity Employer
STATE OF NEW JERSEY
July 22, 2013
Re: Patient Medical Certification and Recertification Applications for
Disability Parking Privileges (New Jersey State Law, N.J.S.A. 39:4-204 through 39:4-207.9)
Dear Member of the New Jersey Medical Community:
Effective August 1, 2013, New Jersey State Law regarding the issuance of parking
privileges for persons with a disability has been amended to help reduce fraud. The
medical certification required to obtain these parking privileges will now expire every three
(3) years. Qualified medical practitioners like yourself will play a vital role in helping
people who need these privileges to keep them.
As in the past, a patient seeking to initially obtain a persons with a disability placard
and/or license plates will continue to ask for your assistance.
One change under the amended law (specifically, N.J.S.A. 39:4-205) is that patients who
seek to retain a persons with a disability placard and/or license plates must submit, to the
MVC, a new medical certification every three years. This certification can only be
obtained from a qualified medical practitioner such as yourself.
The certification that you will be asked to sign, states that the applicant’s disability meets,
or continues to meet, the eligibility criteria that you are asked to specifically select on the
application.
In addition, it is imperative that a clearly written prescription from you for the
placard/license plates be included with the certifying application. Only in the event that
you, the medical practitioner, are not authorized to write prescriptions, will a signed,
formal letter on your official letterhead, addressed to the MVC, be an acceptable
-con’t-
P.O. Box 160
Trenton, NJ 08666-0160
Chris Christie
Governor
Kim Guadagno
Lt. Governor
Raymond P. Martinez
Chairman and Chief Administrator
On the Road to Excellence
www.njmvc.gov
New Jersey is an Equal Opportunity Employer
substitute for the prescription.
With the implementation of the amended law (N.J.S.A. 39:4-205), no application can be
accepted without both the signed certification and a prescription (see above for
substitution circumstance).
Your patient’s application will be rejected without both of these necessary components.
Your National Provider Identifier (NPI) and taxonomy code (classification of health care
providers according to the primary services you render that you specified when applying
for your NPI) must also be supplied on the medical certification.
We’d like you to know that your patients can find the updated application form, that they
need to fill out and present to you, online at www.njmvc.gov. This form must be fully
completed and submitted for all applications, both initial and recertification, for disability
parking privileges.
Also effective August 1, 2013, the types of licensed medical practitioners who are
qualified to authorize these certifications has been expanded to include all of the
following:
• Physicians
• Podiatrists
• Chiropractic physicians
• Physician assistants
• Nurse practitioners
The practitioner must be licensed to practice in the State of New Jersey or a bordering
state. Certifications from physicians stationed at a United States military or naval
installation located in this state and licensed to practice in any state are also acceptable.
Should you require additional information please feel free to contact:
(888) 486-3339
As always, your continued cooperation is greatly appreciated.
Sincerely,
Raymond P. Martinez
MVC Chairman and Chief Administrator
SP-41 (R7/13) Page | 1 of 2
STATE OF NEW JERSEY
License Plate No: ______________________ Placard No: _____________________ Date Issued: __________________ Employee’s Initials: ________________
(FOR COMMISSION USE ONLY: DO NOT WRITE ABOVE THIS LINE)
APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARD FOR
PERSONS WITH A DISABILITY
THIS IS MY: INITIAL APPLICATION RECERTIFICATION APPLICATION REPLACEMENT APPLICATION
I AM APPLYING FOR: LICENSE PLATES PLACARD BOTH
SECTION A: PERSON WITH A DISABILITY IDENTIFICATION CARD INFORMATION
Name of Person with a Disability: ____________________________________________________________________
Street Address: __________________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________________
Driver’s License Number: ____________________________________________ Expires _______________________
Date of Birth: __________________ Sex: ________ Eye Color: ____________Ht: _____________ Wt: ____________
I acknowledge that I hold a Commercial Driver License (CDL) and that this application may result in a medical review
which could result in a decision that may affect my New Jersey CDL privilege.
Current Plate Number: __________________ Current Placard Number: _________________
(for recertification applications)
SECTION B: WHEELCHAIR SYMBOL LICENSE PLATES (photocopy of registration required)
Registered Vehicle Owner’s Name_____________________________ Vehicle Plate No._______________ Expires________
Registered Vehicle Owner’s Driver License Number___________________________________ Expires _______________
Street Address________________________________________ City, State, Zip Code_____________________________
Relationship to the Disabled Applicant: Spouse Parent Guardian Self Other (Please Specify) ________________
SECTION C: REPLACEMENT PLATES, PLACARD AND/OR IDENTIFICATION CARD
LICENSE PLATES PLACARD IDENTIFICATION CARD
Vehicle Plate Number__________________ Expires_________ Placard Number__________________ Expires__________
Check one: Lost– attach notarized statement of loss.
Damaged – return (plate(s), placard and/or ID card).
Stolen – plate(s), placard – attach police report.
SECTION D: CERTIFICATION OF STATEMENTS
I CERTIFY, UNDER PENALTY OF LAW, THAT THE STATEMENTS ON THIS APPLICATION ARE TRUE.
Signature of Registered Vehicle Owner: ________________________________________________Date:___________
Signature of Person with a Disability: __________________________________________________Date: ___________
SECTION E – MEDICAL PRACTITIONER’S CERTIFICATION & SECTION F - TERMS AND CONDITIONS
(on page 2)
Special Plate Unit
P.O. Box 015
Trenton, New Jersey 08666-0015
888-486-3339 (NJ Toll Free)
609-292-6500 (Out-of-State)
SP-41 (R7/13) Page | 2 of 2
MUST BE COMPLETED FOR PROCESSING
APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARDS
FOR PERSONS WITH A DISABILITY
SECTION E: MEDICAL PRACTITIONER’S CERTIFICATION
Name of Medical Practitioner: ________________________________________________
Street Address: _________________________________________________
City, State, Zip Code: __________________________________________ Telephone number: _____________________
National Provider Identification Number (NPI #): ________________________________________ (required)
Taxonomy Code: ____________________________________ (required)
Required prescription attached. Required letterhead attached (ONLY for medical practitioners who are not
authorized to write prescriptions).
By law, eligibility for license plates and/or a placard for persons with a disability is limited to the following conditions.
(NO OTHER PERSON IS ELIGIBLE FOR LICENSE PLATES AND/OR A PLACARD).
Patient Name (print) ____________________________________________________________
1. Has lost the use of one or more limbs as a consequence of paralysis, amputation, or other permanent disability.
2. Is severely and permanently disabled and cannot walk without the use of or assistance from a brace, cane, crutch, another
person, prosthetic device, wheelchair or other assistive device.
3. Suffers from lung disease to such an extent that the applicant’s 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; or uses portable oxygen.
4. Has a cardiac condition to the extent that the applicant’s functional limitations are classified in severity as Class III or
Class IV according to standards set by the American Heart Association.
5. Is severely and permanently limited in the ability to walk because of an arthritic, neurological, or orthopedic condition; or
cannot walk two hundred feet without stopping to rest.
6. Has a permanent sight impairment of both eyes as certified by the N.J. Commission of the Blind (Placard only).
I CERTIFY, UNDER PENALTY OF LAW, THAT MY PATIENT (print name) _________________________________________
HAS BEEN PERSONALLY EXAMINED BY ME AND MEETS THE ELIGIBILITY CRITERIA AS SPECIFIED IN ITEM
NUMBER(S) ______________ (select from above) AND THUS MEETS THE REQUIREMENTS FOR THE RECEIPT OF
LICENSE PLATES AND/OR A PLACARD FOR PERSONS WITH A DISABILITY.
Signature of Medical Practitioner _________________________________________________________ Date______________
SECTION F: TERMS AND CONDITIONS
1. Pursuant to N.J.S.A. 2C:21-4(a), N.J.S.A. 2C:43-3, and N.J.S.A. 2C:43-6, making a false statement or providing misinformation on
an application to obtain or facilitate the receipt of license plates or placards for persons with disabilities is a fourth degree crime and a
person who has been convicted of this offense may be subject to pay a fine not to exceed $10,000 and a term of imprisonment of up
to 18 months.
2. Wheelchair symbol license plates may be issued for one vehicle owned, operated or leased by a person with a disability or family
member providing transportation for that person
.
3. Wheelchair symbol license plates must be renewed every year, disability recertification is required every three years.
4. The placard must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a designated wheelchair
symbol parking space and must be removed when the vehicle is in motion.
5. Persons with a Disability Identification Cards and placards must be recertified every three years.
6. The Motor Vehicle Commission requires that the disability of a person with a disability be recertified by a qualified medical
practitioner certifying their qualification as provided under N.J.A.C. 13:20-9.1(a) 4.
7. The Person with a Disability placard and /or license plates are to be used exclusively for a person with a disability named on the
identification card. The identification card is nontransferable and shall be revoked if used by any other person. If the placard and/or
license plates are no longer used by the person named on the identification card, they must be returned to the New Jersey Motor
Vehicle Commission. Abuse of this privilege is cause for revocation of both the license plates and/or placard.
I CERTIFY, UNDER PENALTY OF LAW, THAT I AGREE WITH THE TERMS AND CONDITIONS OF THIS APPLICATION.
Signature of Registered Vehicle Owner:__________________________________________________Date:_______________
Signature of Person with a Disability: ___________________________ ________________________Date: _______________
SP-41A (R7/13) Page 2 of 3
the aid of an assisting device or whose mobility is otherwise limited as listed on the application and certified by a medical
practitioner, or has a condition that otherwise falls under one of the six (6) categories listed on the application, is eligible for
wheelchair symbol license plates and/or a placard for special parking privileges.
SECTION B: WHEELCHAIR SYMBOL LICENSE PLATES
A LEGIBLE COPY OF THE CURRENT, VALID VEHICLE REGISTRATION MUST BE ATTACHED TO THE
APPLICATION.
THE RELATIONSHIP OF VEHICLE OWNER TO THE PERSON WITH A DISABILITY MUST BE CLEARLY
INDICATED (BOX MUST BE CHECKED).
THE VEHICLE MUST NOT BE REGISTERED TO A BUSINESS/COMPANY, ORGANIZATION OR GROUP.
LICENSE PLATES: Wheelchair symbol license plates may be issued to only one motor vehicle owned, operated, or leased by a
person with a disability or owned by a family member who provides transportation for that person. The vehicle can only park in
designated wheelchair symbol parking spaces when the individual designated on the identification card is either driving or a
passenger in the vehicle. There is no additional charge for the wheelchair symbol license plates beyond the normal cost for regular
plates. Wheelchair symbol license plates cannot be issued for vehicles owned by, or leased to, companies, organizations or groups.
Be certain that you enclose a photocopy of the current (valid) vehicle registration with your application. Failure to submit a legible
copy will cause delays in receiving your plates.
SECTION C: REPLACEMENT PLATES, PLACARD AND/OR IDENTIFICATION CARD
PROVIDE THE VEHICLE PLATE NUMBER AND/OR PLACARD NUMBER.
CLEARLY INDICATE LOST, DAMAGED OR STOLEN (BOX MUST BE CHECKED).
PROVIDE A NOTARIZED STATEMENT AND/OR A COPY OF THE POLICE REPORT (WHICHEVER IS
APPLICABLE).
RETURN THE DAMAGED OR REMAINING ITEMS (WHICHEVER IS APPLICABLE).
If you cannot go to an MVC Agency, mail your original “Person with a Disability Identification Card” and either the damaged
placard or plate, police report, or notarized statement attesting to the loss or theft of the placard/plate to:
Motor Vehicle Commission
Special Plate Unit
PO Box 015
Trenton, NJ 08666-0015
REPLACEMENT IDENTIFICATION CARD: You can go into any MVC Agency to acquire an ID replacement card. Bring your
placard and/or vehicle registration with you. There is no fee for a replacement Person with a Disability Identification Card.
Remember, it is important to always have a current identification card in your possession if you wish to utilize designated
wheelchair symbol parking spaces using either a placard or plates.
REPLACEMENT PLACARD: Damaged, stolen, or lost placards may be replaced by visiting any MVC Agency. If your placard is
damaged, bring the damaged placard and your original “Person with a Disability Identification Card.” If your placard is lost, bring
your original “Person with a Disability Identification Card.” If your placard was stolen, bring your original “Person with a
Disability Identification Card” and a copy of your police report. There is no fee for a replacement placard. If both the Person with a
Disability Identification Card and placard are lost or stolen, but not yet expired, it may be possible to reissue a new placard and
identification card, if you have a driver license or other form of identification and a notarized statement or police report attesting to
the loss or theft of the identification card and placard.
REPLACEMENT PLATES: Damaged, stolen, or lost wheelchair symbol plates may be replaced by visiting any MVC agency. A
notarized statement from the vehicle owner, if not the person with a disability, is required to obtain replacement plates. In addition,
the person with a disability must bring the original “Person with a Disability Identification Card.” If one or both plates were stolen,
a police report is also required. If one plate is lost or stolen, the remaining plate must be surrendered at the MVC agency. If one or
both plates are damaged, both plates must be surrendered.
SECTION D: CERTIFICATION OF STATEMENTS
THE REGISTERED VEHICLE OWNER MUST SIGN AND DATE THE APPLICATION FOR WHEELCHAIR
SYMBOL LICENSE PLATES FOR IT TO BE PROCESSED.
THE PERSON WITH A DISABILITY MUST SIGN AND DATE THE APPLICATION FOR IT TO BE
PROCESSED.
SP-41A (R7/13) Page 3 of 3
It is important for you to know that pursuant to N.J.S.A. 2C:21-4(a), N.J.S.A. 2C:43-3, and N.J.S.A. 2C:43-6, making a false
statement or providing misinformation on an application to obtain or facilitate the receipt of license plates or placards for persons
with disabilities is a fourth degree crime and a person who has been convicted of this offense may be subject to pay a fine not to
exceed $10,000 and a term of imprisonment of up to 18 months.
SECTION E: MEDICAL PRACTITIONER’S CERTIFICATION
THE APPROPRIATE ITEM NUMBER (1-6) INDICATING THE QUALIFYING DISABILITY MUST BE
WRITTEN IN.
THE REQUIRED PRESCRIPTION OR THE REQUIRED LETTER MUST BE ATTACHED (ORIGINALS ONLY,
NO PHOTOCOPIES WILL BE ACCEPTED).
MEDICAL PRACTITIONER MUST SIGN AND DATE THE APPLICATION (DATE MUST BE WITHIN 60 DAYS
OF SUBMITTING THE APPLICATION).
ALL MEDICAL PRACTITIONER INFORMATION MUST BE PROVIDED AND LEGIBLE (NPI NUMBER AND
TAXONOMY CODE ARE REQUIRED).
A medical practitioner’s certification is required as part of the initial and recertification application process. The Motor Vehicle
Commission requires your medical practitioner to certify that you meet the eligibility criteria for the Person with a Disability
identification card, placard and/or license plates. This certification requires a prescription from the medical practitioner for your
condition. If your medical practitioner is not authorized to write prescriptions they are required to write a letter containing the same
information that would appear on a script for your condition. The medical practitioner certification requires the disclosure of that
practitioner’s National Provider Identification Number and their Taxonomy code. Certifications can only be authorized by the
following medical practitioners: a physician, podiatrist, chiropractic physician, physician assistant or nurse practitioner licensed to
practice in this state or a bordering state or a physician stationed at a military or naval installation located in this State who is
licensed to practice in any state.
SECTION F: TERMS AND CONDITIONS
READ STATEMENTS 1 THRU 7 ON THE APPLICATION AND UNDERSTAND THAT PURSUANT TO N.J.S.A.
2C:21-4(A), N.J.S.A. 2C:43-3, AND N.J.S.A. 2C:43-6, MAKING A FALSE STATEMENT OR PROVIDING
MISINFORMATION ON AN APPLICATION TO OBTAIN OR FACILITATE THE RECEIPT OF LICENSE
PLATES OR PLACARDS FOR PERSONS WITH DISABILITIES IS A FOURTH DEGREE CRIME AND A
PERSON WHO HAS BEEN CONVICTED OF THIS OFFENSE MAY BE SUBJECT TO PAY A FINE NOT TO
EXCEED $10,000 AND A TERM OF IMPRISONMENT OF UP TO 18 MONTHS.
THE MEDICAL PRACTITIONER’S CERTIFICATION MUST BE DATED WITHIN 60 DAYS OF THE
APPLICATION SUBMISSION.
THE REGISTERED VEHICLE OWNER MUST SIGN AND DATE THE APPLICATION FOR WHEELCHAIR
SYMBOL LICENSE PLATES FOR IT TO BE PROCESSED.
THE PERSON WITH A DISABILITY MUST SIGN AND DATE THE APPLICATION FOR IT TO BE
PROCESSED.
FREQUENTLY ASKED QUESTIONS
My spouse (or other qualified disabled individual) cannot complete the application and/or is unable travel to an Agency to
file an application. Can someone else complete and deliver the application for them?
Yes, the application can be completed by another individual but the form must be signed by the applicant. (If the applicant cannot
sign the form, a Power of Attorney must be included with the application package). A third party may bring the application to any
local MVC agency for same day processing as long as the individual has proper identification and a notarized statement from the
person with a disability giving them permission to act on his/her behalf.
I have more than one vehicle that I drive. Can I get two sets of plates or two placards?
No. You may have one set of plates or one placard or both depending on your individual needs. This provision of the regulation is
based on the fact that the placard can be used in any vehicle in which you are the driver/passenger as long as you have your “Person
with a Disability Identification Card” with you.
If I mail in my application, how long must I wait for my placard/plates to arrive?
Generally, MVC requires 4-6 weeks to issue plates and placards. Additional time should be allowed for mailing. A checklist is
provided with the application form and instructions to help ensure that the form is completed accurately. Using the checklist will
help avoid delays in processing.
