Application for a Disabled, Disabled Veteran or Motorcycle International Wheelchair Symbol License Plate

If a disabled person wishes to apply for a license plate, he/she has to complete and submit the following application form.

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STATE OF FLORIDA 	
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES 	
DIVISION OF MOTOR IST SERVICES 	
www.flhsmv.gov/offices/	 	 	
APPLICATION FOR A DISABLED, DISABLED VETERAN OR MOTORCYCLE   
INTERNATIONAL WHEELCHAIR SYMBOL LICENSE PLATE  	
 	***** SUBMIT APPLICATION TO YOUR LOCAL COUNTY TAX COLLECTOR’S OFFICE OR LICENSE PLATE AGENCY *****  	 	 I, ___________________________________________________________, certify that I am a legal resident of Florida residing at      
Street Address          City                              State    Zip  
and I am the registered  	 Owner  	 Lessee of the following described motor vehicle:  	  Vehicle Identification Number	 	
 	
Year	 	Make	 	Color	 	Body	 	Florida Title Number	 	
Owner/Lessee 	Date of Birth	 	Sex	 	Current License Plate Number	 	Owner/Lessee E	-Mail Address	 	
 
Florida Driver License or Identification Number: _______________________________________________________________________   I certify that I qualify for the wheelchair symbol license plate as defined in sections 320.0842, 320.0843 or 320.0848, Florida 
Statutes, and I have obtained the appropriate physician/certifying practitioner’s certification.  
 
Choose  one	:      	 Disabled wheelchair  license  plate      	 Disabled Veteran (DV)  Wheelchair license plate 	 
         	 Disabled  Motorcycle  wheelchair license  plate 	  
______________________________________________________________________        ________________________________________  
      SIGNATURE – DISABLED PERSON/VETERAN                         Date                    	 	   	PHYSICIAN/CERTIFYING PRACTITIONER’S STATEMENT OF CERTIFICATION  	
For Disabled Person to Obtain a Regular or Motorcycle Size Wheelchair Symbol License Plate  	 	This is to certify that ____________________________________________________________ is legally blind or is a disabled person with a specific 
disability (ies) that limits or impairs his/her ability to walk 200 feet without stopping to rest.  The specific disability ( ies) is/are checked below: 
 	
 	Legally blind (This is the only disability an Optometrist can certify)  	 
 
  * * * NOTE:  "Unable to walk 200 feet" is no longer a qualifying disability, unless it is due to one of the  conditions listed below (a -f).  * * *   	 	
  a.     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 or the wheelchair symbol license plate. 	
 	
   b.    The need to permanently use a wheelchair.  	 	
  c.	    Restriction by lung disease to the extent that the person’s forced (respiratory) expiratory volume for 1 second, when measured by 
spirometry, is less than one liter or the persons arterial oxygen is less than 60 mm/hg on room air at rest.  	
 	
  d.    Use of portable oxygen  	 	
  e.    Restriction by cardiac condition to the extent that the person’s functional limitations are classified in severity as Class I II or Class IV 
according to standards set by the American Heart Association.  	
 	
  f.     Severe limitation in a person’s  ability to walk due to an arthritic, neurological, or orthopedic condition.  
   
 
                     	
 	Print/Type Name of Certifying Authority          Signature                   Date Signed  
                            	 	Business Street Address                              (Area Code) Telephone Number 
                            	 	City               State                      Zip Code  Certification or License No .  (Required)        	 of Physician, Osteopathic or Podiatric Physician, Chiropractor , Optometrist, 
Advanced Registered Nurse Practitioner under the protocol of a licensed physician or a Physician Assistant licensed under Chapter 458 or 459.  	
 LICENSED IN THE STATE OF: _______________________________ 
WARNING: Any person who knowingly makes a false or misleading statement in an application or certification under section 320.0848,  Florida Statutes, commits a misdemeanor of the first degree, punishable as provided in section 775.082 or 775.083, Florida 
Statutes.  The penalty is up to one year in jail or a fine of $1,000 or both.  
 
 
Check your local phone book government pages or visit the following website for current mailing addresses: 	http://www.flhsmv.gov/offices/	 	 HSMV 83007 (Rev. 02/13)         	www.flhsmv.gov

PROCEDURES AND INSTRUCTIONS 	 	PROVISIONS OF LAW:	 	 	Section 320.0842, Florida Statutes, provides for the issuance of a wheelchair symbol license plate to any owner or lessee of a 
motor vehicle who qualifies as a disabled veteran and also qualifies for a disabled person parking permit under section 320.0848, 
Florida Statutes. 
 Section 320.0843, Florida Statutes, provides for the issuance of a wheelchair symbol license plate to any owner or lessee of a 
motor vehicle who qualifies for a disabled person parking permit under section 320.0848, Florida Statutes.  
 	APPLICATION REQUIREMENTS:	 	 1.  The form HSMV 83007 or 83039 must be accurately completed, including the "Physician/Certifying Practitioner's 
Statement of Certification" section verifying the disability.   See list below for acceptable "certifying authorities." 	
 NOTE:   A disabled veteran must also  provide proof of their eligibility for a license plate as specified in section 
320.084, Florida Statutes.  	
WHEELCHAIR SYMBOL LICENSE PLATE MAY BE USED ON THE FOLLOWING TYPE VEHICLES:	 	
PROVISIONS OF LAW:	 	
 
Section 320.08035, Florida Statutes, provides for the issuance of a wheelchair symbol license plate on a motorcycle when the 
disable d person  meets the requirements defined in Section 320.0848, Florida Statutes.  
 	
APPLICATION REQUIREMENTS:	 	
 
1.   The form HSMV 83007 or 83039 must be accurately completed, including the "Physician/Certifying Practitioner's  
Statement of Certification" section verifying the disability.   See list below for acceptable "certifying authorities." 	
 	2.  A copy of the vehicle registration certificate.  	
MOTORCYCLE WHEELCHAIR SYMBOL LICENSE PLATE MAY BE USED ON THE FOLLOWING TYPE VEHICLES:	 	
 
1.   Motorcycles for private use or lease.  	
CERTIFYING AUTHORITIES:	 	
 
The "Physician/Certifying Practitioner's Statement of Certification"  section on the reverse side of this form MUST be 
completed by one  of the following and must include the certifying authority's license number and the name of the state where their 
license was issued:  
 
•  Physician licensed to practice under Chapters 458, 459 or 460, Florida Statutes, or similarly licensed by another state.  
NOTE:  Documentation of the physician's licensure in the other state must be submitted.  
•   Osteopathic Physician.  
•   Podiatric Physician.  
•   Chiropractor.  
•   Optometrist (for sight  only). 
•   Physician who practices medicine in a military medical facility, state hospital or federal prison.  Indicate the facility and  the 
address.  
•   Advanced registered nurse practitioner licensed under Chapter 464, under the protocol of a licensed physician.  
•   Physician assistant licensed to practice under Chapter 458 or Chapter 459.  
 	
A LICENSE PLATE WILL BE ISSUED AND MUST BE RENEWED ANNUALLY.  	 	Check your local phone book government pages or visit the following website for current mailing addresses: 	http://www.flhsmv.gov/offices/	 	 HSMV 83007 (Rev. 02/13)         	www.flhsmv.gov