Application for Accessible Parking Identification Permits and Plates

Service Nova Scotia

and Municipal Relations

Service Delivery

PO Box 1652, Halifax, Nova Scotia B3J 2Z3

Application for Accessible Parking Identification

Permits and Plates

Day Month Year

I, ______________________________________________________________________________________________________________________

Client or Company Name Date of Birth

__________________________________________________________________________________________________________________________________________________________________________________________

Address in Full Postal Code

hereby certify that I am a MOBILITY DISABLED PERSON as defined by the Regulations respecting Permits/Number Plates for Mobility Disabled Persons.

I hereby make application for Temporary Identification Number

Identification Permit (Permanent Disability)

Number Plates for the Vehicle described below. – PLEASE NOTE: Applicant must be Plate Owner and Operator of Vehicle.

Serial Number Year Make Plate Number

Client Master Number

_________________________________________________ ___________________________________________________________________________

Date Signature of Applicant or Authorized Agent

SECTION 1 - Please print clearly in ink.

SECTION 2

SECTION 3

SECTION 4

MEDICAL CERTIFICATION

(to be completed by a qualified Medical Practitioner)

MOBILITY DISABLED PERSON means a person whose mobility is limited as a result of permanent severe physical disability caused by paralysis, lower

limb amputation, heart or lung disease or other debilitating impairment to the extent that:

(i) the person is unable to propel himself without the aid of a wheelchair or walker, or a combination of two of a crutch, cane, leg brace, or leg prosthesis, or

(ii) (A) the daily use of a device to assist the person with breathing is required, or

(B) the person has a significant cardio-pulmonary condition which results in severe shortness of breath with minimum physical activity, or

(C) the person has a severe neuro-muscular or skeletal condition, and because of any of the conditions described in paragraph (A), (B) or (C) is limited

in mobility to 50 meters or less in outdoor weather conditions, or

(iii) the person is legally blind in accordance with the definition of blindness in the Blind Persons Act (Canada) as may be from time to time amended.

This is to certify that the applicant named above is a PERMANENT MOBILITY DISABLED PERSON as defined above due to:

(Medical Condition) _________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

_________________________________________________ ___________________________________________________________________________

Date Doctor’s Signature

___________________________________________________________________________

Please Print Name

_________________________________________________ ___________________________________________________________________________

Physician’s Phone Number Address

This is to certify that the applicant above is a TEMPORARY MOBILITY DISABLED PERSON due to:

(Medical Condition) _________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

ANTICIPATED LENGTH OF TIME DISABILITY IS EXPECTED TO CONTINUE: ______________________________________________________________________

_________________________________________________ ___________________________________________________________________________

Date Doctor’s Signature

___________________________________________________________________________

Please Print Name

_________________________________________________ ___________________________________________________________________________

Physician’s Phone Number Address

Application for renewal of permanent disabled Plate Permit

This is to certify that my condition has not changed as it relates to qualifying for disabled parking privileges.

Applicant’s Signature _____________________________________________________________ Date ___________________________________________________

APP11 (Rev. 09/10)

(Maximum six months per certification)