Franklin Lakes, MT · Bergen County
Application for Temporary Disability Placard
People seeking an initial temporary disability placard or recertification complete this application with information from their medical practitioner.
What this form is
This application requests a temporary disability placard and includes options for an initial application or recertification. The applicant provides personal and driver information, and a medical practitioner provides contact details, a required National Provider Identification number, and a certification of eligibility. The form also includes terms and conditions, a $4.00 fee checkbox, and fields for police chief use.
Who needs it
A person seeking an initial temporary disability placard or recertification needs this application and a medical practitioner’s eligibility certification.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the medical practitioner certifies eligibility under penalty of law, and the applicant signs and dates the application.
How to submit this form
- 1
Download The Application
Download the Temporary Disability Placard Application.
- 2
Complete Applicant Information
Fill in the applicant information and select initial application or recertification.
- 3
Get Medical Certification
Have a medical practitioner complete the certification section, including the required NPI number.
- 4
Attach The Fee And Submit
The form lists a $4.00 fee payable to NJ MVC. Submit the application to the city department named on the form.
Frequently asked questions
- Do I need a notary for the Temporary Disability Placard Application?
- No. This application is signed without a notary. The medical practitioner certifies eligibility under penalty of law, and the applicant signs and dates the form.
- How do I submit the Temporary Disability Placard Application?
- Submit it to the city department named on the form; check the city website for current contact details.
- Who completes the medical practitioner section?
- A medical practitioner provides contact information, a required National Provider Identification number, and a certification that the applicant meets the stated eligibility criteria.
- What fee does the application list?
- The form has a checkbox for a $4.00 fee payable to NJ MVC to be attached.