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Get Louisiana Mobility Impairment Form 2021-2024

MEDICAL EXAMINER S CERTIFICATION OF MOBILITY IMPAIRMENT I certify that Name Birth Date Address Race/Sex City/State/Zip code meets the requirements as outlined in shown on reverse side and qualifies for a mobility impaired license plate/hang-tag. 4 G 4. PERMANENTLY IMPAIRED Applicant TEMPORARILY IMPAIRED Applicant has a temporary has a total or lifelong condition of mobility impairment from which little or no improvement or recovery can reasonably be expected. A medical examiner s certification is required on initial application only. Condition of mobility impairment from which improvement or recovery can reasonably be expected. Applicant is entitled to a hang-tag which will be valid for one 1 year. A medical examiner s cerification is required for renewal of hang-tag. UNABLE TO APPEAR IN PERSON AT OFFICE OF MOTOR VEHICLES Applicant must bring facial photo. Medical Examiner s Signature Date Printed Name of Medical Examiner State License Address Telephone TO BE COMPLETED BY MOTOR VEHICLE ANALYST ONLY VIN Lic. Plate Hang-tag Control Hang-tag ID Date Issued Operator Office LOUISIANA DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS OFFICE OF MOTOR VEHICLES NOTICE FAILURE TO SUBMIT MEDICAL EXAMINER S CERTIFICATION OF MOBILITY IMPAIREMENT SEE REVERSE SIDE FOR MOBILITY IMPAIRED LICENSE PLATE OR HANDICAP HANG-TAG WILL RESULT IN REJECTION AND/OR RETURN OF APPLICATION. One 1 handicap hang-tag allowed per person. Two 2 mobility impaired license plates allowed per person. HANDICAP HANG-TAGS OR LICENSE PLATE not to be issued/renewed to ANYONE other than the mobility impaired person or designee. I further understand that willful and false cerification shall subject me to fines/imprisonment as outlined in R*S* 47 463. condition of mobility impairment from which improvement or recovery can reasonably be expected* Applicant is entitled to a hang-tag which will be valid for one 1 year. A medical examiner s cerification is required for renewal of hang-tag. UNABLE TO APPEAR IN PERSON AT OFFICE OF MOTOR VEHICLES Applicant must bring facial photo. Medical Examiner s Signature Date Printed Name of Medical Examiner State License Address Telephone TO BE COMPLETED BY MOTOR VEHICLE ANALYST ONLY VIN Lic* Plate Hang-tag Control Hang-tag ID Date Issued Operator Office LOUISIANA DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS OFFICE OF MOTOR VEHICLES NOTICE FAILURE TO SUBMIT MEDICAL EXAMINER S CERTIFICATION OF MOBILITY IMPAIREMENT SEE REVERSE SIDE FOR MOBILITY IMPAIRED LICENSE PLATE OR HANDICAP HANG-TAG WILL RESULT IN REJECTION AND/OR RETURN OF APPLICATION* One 1 handicap hang-tag allowed per person* Two 2 mobility impaired license plates allowed per person* HANDICAP HANG-TAGS OR LICENSE PLATE not to be issued/renewed to ANYONE other than the mobility impaired person or designee. The term mobility impaired person shall include any person who is impaired because of any of the following conditions Cannot walk two hundred feet without stopping to rest. Cannot walk without the assistance of another person walker cane crutches braces prosthetic device or wheelchair.

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