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Com. APPLICATION REQUIREMENTS The form 83039 must be accurately completed including the Physician/Certifying Practitioner s Statement of A Florida driver license number or Florida identification number is required unless the authorized physician certifies that the applicant s disability is too severe to visit or be transported to an office to obtain a driver s license or identification card. This disability must be due to a condition listed in 2 8 on the reverse side of this form in the Physician/Certifying Practitioner s Statement of Certification section. as permanently disabled on the application if the person provides a certificate of disability issued within the last 12 months pursuant to this subsection. RENEWAL INSTRUCTIONS Submit a copy of the registration for your expiring parking permit and a certificate of disability form HSMV 83039. HSMV 83039 - REV. 10/15 PROVISIONS OF LAW Section 316. 1958 Florida Statutes provides that motor vehicles displaying a license plate or parking permit issued to a disabled person by any other state or district subject to laws of the United States shall be recognized as a valid plate or permit allowing such vehicle the special parking privileges in Florida provided such other state or district grants reciprocal recognition for disabled residents of this state. PERMANENT PERMIT This is to certify that the applicant named above is legally blind or is a disabled person with a permanent disability ties that limits or impairs his/her ability to walk 200 feet without stopping to rest. Specify below 2-8 either legally blind or the specific disability ties. DISABILITY TYPE AS DISPLAYED IN FRVIS 2. Inability to walk without the use of or assistance from a brace cane crutch prosthetic device or other assistive device or without assistance of another person. If the assistive device significantly restores the person s ability to walk to the extent that the person can walk without severe limitation the person is not eligible for the exemption parking permit. I am a quadriplegic. PHYSICIAN/CERTIFYING PRACTITIONER S STATEMENT OF CERTIFICATION See Warning Below TEMPORARY PERMIT This is to certify that the applicant named above is a person with a temporary disability six months or less that limits or impairs his/her ability to walk or is temporarily sight impaired. Due to the temporary specific disability ties checked below 2-8 the disabled person parking permit should be issued from date through date. PERMANENT PERMIT This is to certify that the applicant named above is legally blind or is a disabled person with a permanent disability ties that limits or impairs his/her ability to walk 200 feet without stopping to rest. Specify below 2-8 either legally blind or the specific disability ties. DISABILITY TYPE AS DISPLAYED IN FRVIS 2. 0848 Florida Statutes. Name of Disabled Person as printed on their Florida Driver License or Florida ID Card Date of Birth Sex Current Disabled Parking Permit Number if applicable Disabled Person s E-mail Address Address Signature of Disabled Person or Guardian of the Disabled Person City State Required for permanent and temporary parking permits unless exception is noted by physician below Zip I am a frequent traveler. I am a quadriplegic. PHYSICIAN/CERTIFYING PRACTITIONER S STATEMENT OF CERTIFICATION See Warning Below TEMPORARY PERMIT This is to certify that the applicant named above is a person with a temporary disability six months or less that limits or impairs his/her ability to walk or is temporarily sight impaired. Due to the temporary specific disability ties checked below 2-8 the disabled person parking permit should be issued from date through date. PERMANENT PERMIT This is to certify that the applicant named above is legally blind or is a disabled person with a permanent disability ties that limits or impairs his/her ability to walk 200 feet without stopping to rest. FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES APPLICATION FOR DISABLED PERSON PARKING PERMIT SUBMIT APPLICATION TO YOUR LOCAL COUNTY TAX COLLECTOR S OFFICE OR LICENSE PLATE AGENCY www. APPLICATION BY DISABLED PERSON See Warning Below Please Print/Type below I certify that I am a person with one of the disabilities listed in section 320. 0848 Florida Statutes. I further state that my physician or other certifying practitioner has completed the statement of certification below on my behalf as required in section 320. 0848 Florida Statutes. Name of Disabled Person as printed on their Florida Driver License or Florida ID Card Date of Birth Sex Current Disabled Parking Permit Number if applicable Disabled Person s E-mail Address Address Signature of Disabled Person or Guardian of the Disabled Person City State Required for permanent and temporary parking permits unless exception is noted by physician below Zip I am a frequent traveler.