Office Use Only:
Date: ________ Received By: __________________ Zone Issued: ________________
Renew?: Yes / No           Type of Permit: Temporary / Permanent / How Long? ________ Exp.: _________

Mobility impaired faculty, staff and students may be eligible for parking arrangements or issuance of an accessible parking permit. Approval is dependent upon the completion of this application by the client’s physician, and if the disability falls within the following criteria as determined by Transportation. Disabled shall mean a person with a mobility impairment who, as determined by a licensed physician: (a) Cannot walk 200 feet without stopping to rest (b) Cannot walk without the use of a supporting device or another person (c) The disability is a result of restricted mobility due to pulmonary or cardiovascular disease, or an arthritic or orthopedic condition (d) Blindness or whose vision with glasses is so defective as to prevent the performance of ordinary activity for which eyesight is essential, (e) Pregnancy when there are extenuating circumstances, complications or limitations involved. Consideration is given to post-surgical applicants as well as other individuals as circumstances warrant. For assistance in determining eligibility, please contact Transportation at 919-515-3424. Return this completed form to Transportation, Box 7221, Raleigh, NC 27695-7221. Forms can be faxed to the Attention of the Accessibility Coordinator at 919-515-7650. Due to limited availability of parking on our campus, it is imperative that accessibility permits are only issued to individuals who truly need them.

Physician’s Name (Print or Type): ________________________________

Signature:___________________________________________ Date: ___________

Name of Practice: _____________________________Office Location (City): ___________________
Phone: ________________ Fax: ______________________

Please use terminology easily understood by non-medical staff.
1. Please describe the condition: _________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

2. Duration of Impairment: (  ) Permanent – Must obtain state DMV placard. (  ) Temporary – 6 Week or More DMV Placard
Duration in weeks: ____________ Duration in months: _____________

3. Does person require a walking device? (  ) NO (  ) YES
4. Please indicate the maximum distance that can be negotiated without endangering patient’s health (Circle one):
<200 Ft.    200-300 Ft.     400 Ft.     2-3 Blocks     3-4 Blocks     >4 Blocks

5. Can the individual park in an outer lot and ride our transit system (which is fully accessible) with this condition? (  ) YES (  ) NO If no, please describe why not: ____________________________________________________________________________________________________

________________________________________________________________________________________________________________

6. Are hills or steps a problem? ( ) YES ( ) NO