STATE OF ALASKA DEPARTMENT ADMINISTRATION DIVISION MOTOR VEHICLES 861
User Manual: 861
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STATE OF ALASKA DIVISION OF MOTOR VEHICLES APPLICATION FOR SPECIAL DISABILITY PARKING PERMIT PART 1. TO BE COMPLETED BY APPLICANT (APPLICANT MUST BE THE PERSON NAMED AS “PATIENT” IN PART 2.) FULL LEGAL NAME OF APPLICANT (PRINTED) MAILING ADDRESS CITY / STATE / ZIP ID OR DRIVER LICENSE NUMBER STATE DATE OF BIRTH SEX M EMAIL F DAYTIME TELEPHONE NUMBER ( ) PART 2. TO BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT, NURSE PRACTITIONER OR PODIATRIST NAME OF PATIENT: ___________________________________________________________________________ To obtain a disability parking permit, the patient must meet one of the following requirements. Please check any that apply. 1. Cannot walk 200 feet without stopping to rest 2. Cannot walk without using a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device 3. Is restricted by lung disease 4. Uses portable oxygen 5. Has a cardiac condition classified as Class III or Class IV according to standards set by the American Heart Association 6. Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition THIS DISABILITY IS: PERMANENT (valid for five years and renewable upon reapplication) (must have valid Alaska ID or License) TEMPORARY (valid up to six months and renewable upon reapplication) Starting Date (mo/yr) __________ Ending Date (mo/yr) __________ Does your patient have a commercial driver license (CDL)? YES NO If YES, does your patient meet the physical requirements under 49 CFR 391.41 to retain their CDL? YES NO I certify as a licensed Alaskan physician, physician assistant, nurse practitioner, or podiatrist that the patient shown as the applicant in Part 1 meets the definition(s) above and is eligible for a special disability parking permit or license plates with parking privileges. AUTHORIZED SIGNATURE TITLE (CIRCLE ONE) Physician PRINTED NAME & OCCUPATIONAL LICENSE NUMBER PA DATE Podiatrist CITY & ZIP CODE Nurse Practitioner / TELEPHONE NUMBER ( ) PART 3. DMV USE ONLY VISITOR/TOURIST PERMIT / PLATE # PERMANENT TEMPORARY ORGANIZATION NEW PERMIT OR PLATE # BATCH OFFICE LOGIN ID Date Supervisor LOGIN ID Date Form 861 (Rev. 11/2016) alaska.gov/dmv REPLACEMENT - PREVIOUS / 20 How Do I Apply? Complete the application for a special disability parking permit (Form 861) Part 1 available at your local DMV or online at Alaska.gov/dmv. A licensed physician, physician’s assistant, nurse practitioner, or podiatrist must complete Part 2 of the form certifying your qualifying conditions. Who Is Eligible? Individuals with a temporary or permanent disability are eligible for a special disability parking permit when they meet one of the following requirements: • Cannot walk 200 feet without stopping to rest; • Cannot walk without using a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device; • Are restricted by lung disease; • Use portable oxygen; • Have a cardiac condition classified as Class III or Class IV according to standards set by the American Heart Association; • Are severely limited in ability to walk due to an arthritic, neurological, or orthopedic condition. Permit or Plates? Individuals who experience a temporary disability are eligible to obtain a special disability parking permit to park in designated parking spaces. Individuals with a permanent disability may obtain either a special disability parking permit or disability license plates. Registration and taxes are waived for the first set of disability license plates. Full fees are required for second or subsequent sets of disability license plates. Where Do I Hang the Special Disability Parking Permit? Hang the special disability parking permit from your rearview mirror when parked in a designated parking space. Be sure to remove the permit from your rearview mirror before driving since it can obstruct your vision. When Does My Special Disability Parking Permit Expire? Permanent special disability parking permits are issued up to five years and are renewable in your local DMV office. Temporary disability parking permits are issued up to six months and renewable upon reapplication and doctor certification. The expiration date is printed on the permit and expires on the last day of the month shown on the permit. Who Can Use My Special Disability Parking Permit or Plates? Your special disability parking permit allows you to park in designated parking areas. Anyone transporting the holder of a special disability parking permit may also park in designated parking when the holder of the permit enters or exits the vehicle. (907) 269-5551 Form 861 (Rev. 11/2016) alaska.gov/dmv
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