PERSON WITH A DISABILITY PARKING PERMIT APPLICATION

Form PA-3 Instruction Sheet

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PERSON WITH A DISABILITY PARKING PERMIT APPLICATION FORM

INSTRUCTION SHEET (FORM PA-3)

SIDE 1 – TO BE COMPLETED BY APPLICANT

1. APPLICANT INFORMATION. Print or type your name, beginning with your first name, middle initial, then last

name. Only include a suffix (Jr., Sr., III, etc.) if applicable.

2. PHONE NUMBER. Print your telephone number, including the area code. If you do not have a telephone

number, write “NONE.”

3. EMAIL ADDRESS. Enter your email address if you have one. This is optional. DCAB will use it ONLY to contact

you for parking program purposes.

4. DATE OF BIRTH. Print the month, day and year. Example: If your date of birth is June 30, 1965, you

would print 06/30/1965.

5. HEIGHT. Print your height in feet and inches.

6. WEIGHT. Print your weight in pounds.

7. GENDER. Mark the box for either Male or Female.

8. MAILING ADDRESS. Print your mailing address.

9. INDICATE THE COUNTY WHERE YOU LIVE. Answer only if you live in Hawaii. Mark the box next to the

county where you reside. Mark one box only.

10. PARKING PLACARD REQUEST. Mark the box next to the type of placard you are requesting.

• First time application. Mark this box if this is the first time that you are applying for a temporary (red)

placard, long term (blue) placard, Disability Paid Parking Exemption Permit/DPPEP (green) placard, or

special license plates. A temporary (red) placard will be valid for no more than 6 months. There is a $12 fee

for a temporary (red) placard. There is no fee for a first time long term (blue) placard or a first time DPPEP

(green) placard.

• Second placard. Mark this box if you want a second temporary (red) placard. A second temporary (red)

placard is an additional placard that has the same expiration date as its companion placard. There is a $12

fee for a second temporary (red) placard.

• Renewing placard. Mark this box to renew your temporary (red) placard, long term (blue) placard, or

Disability Paid Parking Exemption Permit/DPPEP (green) placard. You may apply up to 60 days before it

expires. Print the placard number of your expiring or expired placard(s) in the space provided. Check your

blue I.D. card for your placard number(s). If you currently have two temporary (red)

placards and want two

renewal temporary (red) placards, enter the placard number of each expiring or expired placard in the

spaces provided. There is a $12 fee for renewing each temporary (red) placard. There is no fee to renew a

long term (blue) placard or Disability Paid Parking Exemption Permit/DPPEP (green) placard. YOU MUST

ALSO HAVE YOUR DISABILITY RECERTIFIED BY A LICENSED PRACTICING PHYSICIAN/ADVANCED

PRACTICE REGISTERED NURSE (APRN).

• Replacing a confiscated, lost, stolen, or mutilated temporary (red) placard or long term (blue) placard.

Mark this box if your temporary (red) placard or long term (blue) placard was confiscated, lost, stolen, or

mutilated and is still valid. Print the placard number(s) in the space provided. Check your blue I.D. card for

the placard number(s). There is a $12 fee for replacing a confiscated, lost, or stolen temporary (red) placard

or long term (blue) placard. There is no fee for replacing a mutilated placard, but you must bring in its

remaining parts, otherwise, it will be treated as replacing a lost placard and a $12 fee will apply. Side 2 of

the form should be left blank.

• Replacing a confiscated, lost, or stolen Disability Paid Parking Exemption Permit/DPPEP (green)

placard. Mark this box if your DPPEP (green) placard was confiscated, lost, or stolen and is still valid. Print

the placard number in the space provided. Check your blue I.D. card for the placard number. The

replacement fees are as follows: first replacement $30, second replacement $60, third replacement $90,

and any subsequent replacement $120. Side 2 of the form should be left blank.

• Replacing a

mutilated Disability Paid Parking Exemption Permit/DPPEP (green) placard. There is no fee

for replacing a mutilated DPPEP (green) placard that is still valid. You must mail in its remaining parts,

otherwise, it will be treated as replacing a lost placard and a fee will apply. Side 2 of the form should be left

blank.

11. SPECIAL LICENSE PLATES REQUEST. Mark only if requesting Special License Plates. You must provide

information where indicated. You may obtain one set of plates and one long term (blue) placard or one Disability

Paid Parking Exemption Permit/DPPEP (green) placard.

12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION. Read the information

carefully. This is your statement that you understand the terms of using the placard or special license plates.

Sign and date the statement. If you are unable to sign due to your disability, your authorized representative may

sign on your behalf.

Form PA-3 Instruction Sheet

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SIDE 2 – TO BE COMPLETED BY A PHYSICIAN, PHYSICIAN ASSISTANT OR

AN ADVANCED PRACTICE REGISTERED NURSE ONLY IF SIDE 1 IS COMPLETED FIRST

13. (Required) CERTIFICATION OF CONDITION. To qualify for a disability parking permit, the physician, physician

assistant or Advance Practice Registered Nurse (APRN) must certify that the applicant has a disability that limits

or impairs the ability to walk 200 feet without stopping to rest and has been diagnosed with at least one of the

conditions listed in (A) AND at least one of the functional impacts of the condition in (B).

Do not provide certification unless at least one condition listed in (A) and at least one condition listed in

(B) is true as it pertains to the applicant.

NOTE: Under (B), certifying that the applicant cannot walk 200 feet without stopping to rest means the

applicant cannot walk 200 feet under the applicant's own power without stopping to rest.

The following conditions do not qualify: visual impairments; mental illness; old age; infancy; deafness; upper

limb amputation; pregnancy; behavioral, learning, intellectual or developmental disabilities.

14. (Required) DURATION OF DISABILITY. Mark the box that corresponds to the expected duration of the

qualifying disability. If the expected duration is less than six years, mark the box next to the month of the

expected duration on the Temporary line. Subsequent certifications can be made if the disability lasts longer

than six months. If the disability is expected to last a minimum of six years, mark the 6 years box on the Long

Term line.

15. (Optional) UNABLE TO APPLY IN PERSON. Mark only if the applicant is unable to apply in person due to a

medical condition.

16. (Required) PHYSICIAN/ PHYSICIAN ASSISTANT/ APRN CERTIFICATION. Input the following information:

• Print physicianʻs/ physician assistant’s/ APRNʻs full name, phone number and mailing address.

• Input medical license number (must be a Hawaii license unless military stationed in Hawaii).

• Circle medical license type (only listed types are accepted).

• Signature and date (apply to date of certification). A digital signature is accepted. A fax or photocopy of the

physicianʻs/ physician assistant’s/ APRNʻs signature will NOT be accepted.

17. (Optional) CERTIFICATION FOR DISABLED PAID PARKING EXEMPTION PERMIT/DPPEP.

Certification is appropriate under this section only if the applicant has (1) a valid driverʻs license and (2) one of

the three conditions listed is true as it pertains to the applicant. Do not certify if the applicant does not

qualify. If certifying the applicant for a DPPEP, full completion of sections 16 and 17 is required.

GIVE COMPLETED ORIGINAL FORM BACK TO APPLICANT. MAY RETAIN A COPY FOR MEDICAL FILE.

______________________________________________________________________

WHERE TO SUBMIT THE COMPLETED APPLICATION

First Time and Replacement of Temporary (red) and Long term (blue) Placards; Renewal of Temporary (red)

Placards, and Special License Plates Applications.

Applicant must submit this form to a county issuing site. If the Physician/Physician Assistant/APRN certifies that the

applicant is unable to appear in person because of a medical condition (see section 15 on Side 2), the applicantʻs

authorized representative must present the applicant’s original I.D. along with the completed application form.

A fax or photocopy of the applicantʻs completed form will NOT be accepted.

Renewal of a Long Term (blue) Placard.

Completed original form must be mailed to:

DCAB

P.O. Box 3377

Honolulu, HI 96801

First Time, Replacement, or Renewal of a Disabled Paid Parking Exemption Permit/DPPEP (green) Placard.

Completed original form, a copy of the applicantʻs valid driver’s license, and payment if the application is for a

replacement DPPEP placard, must be mailed to:

DCAB

P.O. Box 3377

Honolulu, HI 96801

FORM PA-3 SIDE 1 PHONE: 808-586-8121 WEB: www.hawaii.gov/health/dcab July 2022

STATE OF HAWAII DISABILITY AND COMMUNICATION ACCESS BOARD

DISABILITY PARKING PERMIT APPLICATION

Applicant must present valid I.D to the issuing agency or if mailing the form, attach a legible copy.

If certifying physician, physician assistant or APRN completes section 17, attach a copy of the applicant’s

valid driver’s license.

SUBMITTING THIS FORM:

First time $12 temporary (red) placard, or a no fee long term (blue) placard, or special license plates,

or renewing a $12 temporary (red) placard submit form and valid I.D. to a county issuing site:

Honolulu Satellite City Hall, Maui Division of Motor Vehicles, Kauai County Finance Department,

Hawaii County the Office and of Aging

Replacing a confiscated, lost, stolen, or mutilated temporary (red) or long term (blue) placard – submit

form, valid I.D., and a $12 payment to a county issuing site.

No payment required for mutilated placards that are submitted to a county issuing site.

Renewing an expiring long term (blue) placard – mail form to: DCAB, P.O. Box 3377, Honolulu, HI 96801.

Disabled paid parking exemption permit (DPPEP) (green) for first time, renewing, or replacing – mail

form and a copy of valid driver’s license to: DCAB, P.O. Box 3377, Honolulu, HI 96801. For

DPPEP application, #16 and #17 must be completed by physician/physician assistant/APRN.

APPLICANT INFORMATION (Please print or type clearly)

9. INDICATE THE COUNTY WHERE YOU LIVE

City and County of Honolulu County of Hawaii County of Kauai County of Maui

10. PAR

KING PLACARD REQUEST

First time application (red, blue, or green placard, (DPPEP); special license plates) Second temporary (red) placard

Renewing placard # _____________________________ Second (red) placard (if any) # _______________________

Replacing a confiscated, lost, stolen, or mutilated temporary (red) or long term (blue) placard #___________________

Replacing a confisatced, lost, or stolen DPPEP (green) placard # E _________________________________

irst replacement $30/ Second replacement $60 / Third replacement $90 / Subsequent replacements $120

Mail application with check or money order made payable to: Department of Health

Replacing a mutliated DPPEP (green) placard # E_____________________________

(include placard with form)

11. COMPLETE ONLY IF REQUESTING SPECIAL LICENSE PLATES FROM A COUNTY ISSUING AGENCY (DP)

I currently have special license plates. DP #____________________ Plates were confiscated, lost, or stolen.

I am requesting special license plates. I am the registered owner of the vehicle on which the special license plates will

be affixed, AND the vehicle will be used primarily to transport me.

Year of Vehicle

Make

Model

Vehicle Lic. #

Vehicle Registration Expiration Date

12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION. I declare, under the penalties of the penal law, that the

statements contained herein are, to the best of my knowledge and belief, true and accurate, and that I have not knowingly and willingly made a false

statement or given information which I know to be false in connection therewith. I authorize DCAB to contact the email listed in #3 if provided. I also

uthorize the physician, physician assistant or advanced practice registered nurse to release medical information necessary to process this

application.

______________________________________________________________ ___________________________________

APPLICANT SIGNATURE (or Authorized Representative) Date (mm/dd/yyyy)

1. FIRST NAME

MIDDLE INITIAL

LAST NAME

SUFFIX

2. PHONE NUMBER

3. EMAIL ADDRESS (optional)

4. DATE OF BIRTH (mm/dd/yyyy)

5. HEIGHT (Feet, Inches)

6. WEIGHT (Pounds)

7. Gender

Male Female

8. MAILING ADDRESS

APT #

CITY

STATE

ZIP CODE

FOR OFFICIAL USE ONLY

First Placard #________________

Second Placard #______________

Expiration Date _______________

License Plates #_______________

FEES COLLECTED, IF APPLICABLE

Amount Collected $ ______________

____________ ____________

Clerk’s Initial Date

CERTIFICATION BY LICENSED PRACTICING PHYSICIAN/PHYSICIAN ASSISTANT/APRN

All sections on this page must be completed by a licensed practicing physician or physician assistant (AMD) (as defined under Hawaii Revised Statutes

(HRS) §§453, 455, or 463E) or an advanced practice registered nurse (APRN) (as defined under HRS §457). The physician, physician assistant or

APRN must certify that the applicant (1) has a disability that limits or impairs the ability to walk and (2) has one or more of the specific disabilities listed

under items A and B (as defined under HRS §291-51). Individuals who belong to any of the following classes do not qualify for a permit based solely on

that status; persons who have a visual impairment; persons who have a mental illness; persons who are old; persons who are infants; persons who are

deaf; persons who have an upper limb amputation; persons who are pregnant, and persons who have a behavioral, learning, intellectual, or

developmental disability.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. CERTIFICATION OF CONDITION (must check at least one box in (A) and at least one box in (B)):

I certify that applicant name: _____________________________ has a disability that limits or impairs their ability to walk 200 feet

without stopping to rest and has been diagnosed with one of the following conditions:

(A) (i) Arthritic Neurological Orthopedic Oncologic Renal Vascular

(ii) LUNG DISEASE:

FEV < 1L – Forced (respiratory) expiratory volume for one second, when measured by spirometry, is less

than one liter.

P3O2 < 60 mm/hg – Arterial oxygen tension is less than sixty mm/hg on room air at rest.

(iii) CARDIAC CONDITION according to the American Heart Association Standards:

Class III – Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at

rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.

Class IV – Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.

Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any

physical activity is undertaken discomfort is increased.

AND

(B) Because of the condition identified in #13A, the applicant (must check at least one):

Cannot walk 200 feet (under his/her own power) without stopping to rest

Cannot walk (under his/her own physical power) without the use of, or assistance from, the following:

Artificial Lower Limb(s) Brace(s) Crutches Walkers Cane(s) (excluding white cane)

Another Person Wheelchair Other Assistive Device (specify): ________________________________________________________

Uses portable oxygen

14. DURATION OF DISABILITY:

Mark one box only. If the disability lasts longer than anticipated, subsequent certification can be made.

Temporary 1 month 2 months 3 months 4 months 5 months 6 months

Long Term 6 years (only check if disability is expected to last a minimum of 6 years)

15. APPLICANT IS UNABLE TO APPLY IN PERSON (Mark only if applicable)

I certify that this applicant is physically unable to apply in person due to a medical condition. _________________________________________________________________________________

Physician, Physician Assistant, APRN Signature

16. REQUIRED.

PHYSICIAN/AMD/APRN CERTIFICATION. I understand that per HRS

291-51.4, a physician/AMD/APRN who fraudulently verifies that the

applicant is qualified for purposes of this form shall be guilty of a petty misdemeanor and each fraudulent verification shall constitute a separate offense.

DCAB conducts random checks to verify the authenticity of certifications.

FIRST NAME

LAST NAME

PHONE NUMBER

MAILING ADDRESS

CITY

ZIP CODE

MEDICAL LICENSE NO.

(Hawaii or U.S. Armed Services Stationed in HI)

CIRCLE ONE: MD /MDR / ND / DOS / DOSR / PO / APRN / AMD / NPI

PHYSICIAN/ PHYSICIAN ASSISTANT/APRN SIGNATURE

DATE (mm/dd/yyyy)

17. OPTIONAL. CERTIFICATION FOR DISABLED PAID PARKING EXEMPTION PERMIT: COMPLETE ONLY IF APPLICANT

QUALIFIES. To qualify, applicant MUST have (1) a VALID DRIVER’S LICENSE, (2) a mobility disability described in #13(A) and #13(B)

above, and (3) one of the conditions below. I physician/ physician assistant/APRN certify that: (check at least one)

The applicant cannot reach above the applicant’s head to a height of 42 inches from the ground due to a lack of finger, hand,

or upper extremity strength or mobility;

The applicant cannot approach a parking meter due to the use of a wheelchair or other mobility device; or

The applicant cannot manage, manipulate, and insert coins, bills, or cards in a parking meter or pay station due to a lack of fine

motor control in both hands

FIRST NAME

LAST NAME

PHONE NUMBER

MAILING ADDRESS

CITY

ZIP CODE

MEDICAL LICENSE NO.

(Hawaii or U.S. Armed Services Stationed in HI)

CIRCLE ONE: MD /MDR / ND / DOS / DOSR / PO / APRN / AMD / NPI

PHYSICIAN/ PHYSICIAN ASSISTANT/APRN SIGNATURE

DATE (mm/dd/yyyy)

FORM PA-3 SIDE 2 PHONE: 808-586-8121 WEB: www.hawaii.gov/health/dcab July 2022