Date: ________ Received By: __________________ Zone Issued: ________________
Renew?: Yes / No Type of Permit: Temporary / Permanent / How Long? ________ Exp.: _________
NC State University Application for Accessibility Parking
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. 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. For assistance in determining eligibility and to verify receipt of completed faxed forms, please contact Transportation at 919-515-3424. Due to limited availability of parking on our campus, it is imperative that accessibility permits are only issued to individuals with a documented need.
Individual Requesting Parking: ____________________ Signature to Release Info: __________________
- Impairment: ( ) Permanent ? Must obtain state DMV placard. ( ) Temporary ? 6 Week or More DMV Placard
Dates of Temporary Impairment___________________________________
- Does person require a walking device? ( ) NO ( ) YES
- 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
- 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:
- Can the individual navigate hills or steps? ( ) YES ( ) NO
To be completed by Physician
I certify that the individual is disabled for purposes of parking privileges.
Physician's Name (Print or Type): ________________________________
Signature:___________________________________________ Date: ___________
Name of Practice: _____________________________Office Location (City): ___________________
Phone: ________________ Fax: ______________________
Return this form to Transportation / Box 7221, Raleigh, NC 27695-7221
Phone: 919-515-3424 Fax:919-515-7650