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The Nassau Parking Application form, designed specifically for individuals with disabilities within Nassau County, is a crucial document for obtaining a state handicapped parking permit. This application requires the disabled person to provide personal information, including their name, address, date of birth, and phone number. Additionally, applicants must disclose whether they have a handicapped license plate and provide relevant identification numbers. An important aspect of this form is the medical certification section, which must be completed by a licensed medical physician in New York State. Here, the doctor verifies the applicant's mobility impairment and confirms the medical conditions that qualify for a handicapped permit. The form outlines specific criteria, including both permanent and temporary disabilities, and emphasizes the necessity for complete and accurate information. For successful approval, all applicants must be residents of Nassau County, and the application must be submitted in the name of the individual with the disability, even if they are not the driver. Furthermore, incorrect submissions—such as copies or faxes—will be immediately denied. Ensuring compliance with these requirements guarantees access to the necessary parking accommodations for those in need.

Nassau Parking Application Example

NASSAU COUNTY OFFICE FOR THE PHYSICALLY CHALLENGED STATE HANDICAPPED PARKING PERMIT APPLICATION

60 CHARLES LINDBERGH BOULEVARD, UNIONDALE, N.Y. 11553 (516) 227-7399

PART I PERSONAL INFORMATION (To be completed by disabled person)

Name of Disabled Person_____________________________________________________________________________________

(please print )lastfirstmiddle initial

Address___________________________________________________________________________________________________

house number, street (NO P.O. Box)

city

zip code

county

state

HomeTelephone_____________________________

Date of Birth ______________________

Male

Female

Do you have a handicapped license plate? No_________ Yes_________ If yes, License Plate No.___________

Current Drivers License ID Number/Non Drivers License ID Number Do not have Drivers License/Non Drivers License

I hereby certify that the above statements are true and authorize the physician named to furnish any information requested by the Nassau County Office for the Physically Challenged concerning the diagnosis, prognosis and treatment of my described condi- tion. I further acknowledge that I have read and understand the conditions of this application and the Handicapped Parking Permit, and shall observe and comply with same.

Date

SIGNATURE OF APPLICANT OR GUARDIAN

PART II MEDICAL CERTIFICATION INFORMATION (To be completed by a New York State licensed medical physician).

Name of Physician

 

 

 

Phone #

Address

 

 

 

 

 

 

 

 

 

 

 

Physicians’s

Name of Patient

 

 

NYS Practicing License #

 

 

Please Check and describe below applicable condition(s):

“Severely Disabled Person”. shall mean any person who has any one or more of the following impairments, disabilities or condi- tions which are permanent in nature.

(a)_____ Has limited or no use of one or both lower limbs; (State disability and describe below:)

(b)_____ Has a Neuro-muscular dysfunction which severely limits mobility; (state disability and describe below)

(c)_____ Has a physical or mental impairment of condition which is other than those specified above, but is of such nature as

to impose unusual hardship in utilization of public transportation facilities and such condition is certified by a physician duly licensed to practice medicine in this state as constituting an equal degree of disability (specifying the particular condition) so as to prevent such person from getting around without great difficulty in accordance with subdivision two of this section; or

(d)_____ A legally blind person

 

State Permanent diagnosis:

 

Please describe handicapped condition:

 

Temporary ?: _______

How long is

_______ Doctor must state walking device used ______________________

 

 

Permit needed?:

TEMPORARY DISABILITY: A temporarily disabled person is any person who is unable to ambulate without the aid of an assisting device, such as a brace, cane, crutch, prosthetic device, wheelchair, walker or other assistive device. (temporary permits are issued for periods of six months or less). New application required after that.

State temporary diagnosis:_________________________________________________________________________________

I am an MD licensed to practice in New York State, and in my professional opinion, I believe the applicant’s mobility impairing condition does warrant a handicapped Parking Permit, according to the above New York State definition of

“SEVERELY DISABLED.”

Yes________ No_________

 

 

Date: ___________________

 

 

 

 

 

 

 

 

SIGNATURE OF PHYSICIAN (No stamps accepted)(MD/DO/DPM/NP)

 

 

 

 

 

 

 

 

 

 

 

 

For Office Use Only

 

 

 

 

 

Permit No. _____________________

Date Issued ________________

Expiration Date _____________

Permanent

Temporary

HP4594 5/79/ Rev. 11/08

See Reverse Side

INSTRUCTIONS FOR APPLICATION

1.MUST BE A NASSAU COUNTY RESIDENT.

You are eligible for a permit if you are a resident of Nassau County who has one or more servere disabilities that impair your mobility.

All applications must have a Nassau County street address (No Post Office Boxes).

2.All applications must be fully completed and properly executed.

All questions must be answered and Medical Certification MUST be completed by a New York State Practicing Licensed Medical Doctor. All Applications must be signed not stamped.

*****NO CHIROPRACTOR *****

3.All permits are issued in the name of the person with the disability, therefore all Information on application must pertain to the disababled applicant.

You do not have to be the driver . Children and non drivers can apply for a permit. Application must be in the name of the person with the disability.

4.The Department of New York State Motor Vehicles requires the disabled person’s

New York State Drivers License Client ID number or on a NYS ID card to be on the permit. Enclose a copy of disabled applicants ID (not the person driving them) with this Completed application.

5.COPIES OR FAXES of Applications will result in immediate denial.

6.To expedite the issuance of your permit upon approval, please enclose a self-addressed (number 10 size) envolope.

7.Any FALSE statement on the application by the applicant or by the doctor will result in refusal to issue a permit.

Form Characteristics

Fact Name Fact Description
Eligibility Requirements Applicants must be residents of Nassau County and have one or more severe disabilities that impair their mobility.
Medical Certification A New York State licensed medical physician must complete the medical certification section of the application.
Application Submission Applications must be fully completed and cannot be submitted via fax or copies, as this will result in immediate denial.
Permit Ownership The permit is issued in the name of the person with the disability, allowing non-drivers and children to apply.

Guidelines on Utilizing Nassau Parking Application

After completing the Nassau Parking Application form, submission to the Nassau County Office for the Physically Challenged is necessary. The application must be filled out accurately and truthfully to ensure a prompt review and potential approval for the handicapped parking permit.

  1. Start by providing your personal information. Print the name of the disabled person clearly, including the last name, first name, and middle initial.
  2. Fill in the address, including house number, street (no P.O. Box), city, zip code, county, and state.
  3. Enter the home telephone number and date of birth. Indicate the gender by checking either "Male" or "Female."
  4. Inquire about a handicapped license plate. If applicable, check "Yes" and provide the license plate number.
  5. For the driver's license section, provide the current driver's license ID number or the non-driver's license ID number. If neither applies, indicate that you do not have one.
  6. Certify that the information you provided is true by signing and dating the application. If applicable, a guardian may also sign.
  7. The medical certification information must be completed by a New York State licensed physician. Fill in the physician's name, phone number, and address.
  8. The physician needs to check the relevant condition(s) that apply. Describe any disabilities as needed.
  9. Provide a clear and permanent diagnosis along with a description of the handicapped condition.
  10. If applying for a temporary permit, mark the appropriate section and state the length of the temporary condition.
  11. Ensure that the physician indicates whether the mobility-impairing condition warrants a handicapped parking permit. The physician must date and sign in the designated area.
  12. Double-check that all sections are completed and sign the document where required before submission.
  13. Once completed, do not forget to include a copy of the disabled applicant's ID with the application.

It is crucial to keep in mind that faxed or copied applications will not be accepted, and every application must be originals only. Once the form is submitted with all required information, you can expect further instructions regarding the processing of your application.

What You Should Know About This Form

What is the Nassau Parking Application form?

The Nassau Parking Application form is a document used to request a State Handicapped Parking Permit for individuals with severe disabilities that impair their mobility. The application is processed by the Nassau County Office for the Physically Challenged and requires personal and medical information to determine eligibility.

Who is eligible to apply for a permit?

To be eligible for a handicapped parking permit, you must be a resident of Nassau County and have one or more severe disabilities that significantly limit mobility. The application must be completed with a valid Nassau County street address; P.O. Boxes are not acceptable.

What information is required in the application?

The application requires personal information about the individual with the disability, including their name, address, contact number, and date of birth. Additionally, medical certification must be completed by a licensed medical physician in New York State, detailing the applicant's condition and the specific mobility impairment.

Can children or non-drivers apply for a permit?

Yes, children and non-drivers can apply for a handicapped parking permit. The application must be submitted in the name of the person with the disability, regardless of whether they are the driver or not. All personal information must pertain to the individual with the disability.

What happens if the application is incomplete or contains false information?

If the application is not fully completed or contains any false statements from the applicant or the physician, the request for the permit will be denied. It is crucial to ensure that all sections of the application are answered accurately and completely.

Is there a time limit on temporary permits?

Yes, temporary permits are issued for a period of six months or less. After this period, a new application must be submitted to request an extension or a new permit. The medical certification must also be updated to confirm ongoing eligibility.

How should the application be submitted?

The completed application must be mailed to the Nassau County Office for the Physically Challenged. It is important to include a self-addressed envelope to expedite the return of your permit upon approval. Additionally, the application must be signed by the applicant or their guardian, as stamped signatures are not accepted.

What is the significance of including identification documentation?

To process the application, a copy of the disabled person's New York State Driver’s License Client ID number or their NYS ID card must be included. This identification must belong to the individual applying for the permit, not the person who drives them. Including accurate identification aids in a smooth review process.

Common mistakes

Completing the Nassau Parking Application form can be straightforward, but many individuals still make critical mistakes that lead to delays or outright denial. One common error is failing to provide a complete and correct address. It is essential to include a Nassau County street address; using a P.O. Box will render the application invalid. Applicants must clearly identify their residence to ensure eligibility.

Another notable mistake is neglecting to answer all questions. The application requires comprehensive information about the disabled person and their condition. Omissions in personal information or medical details can lead to processing delays or a rejection of the application altogether. This step is vital; no detail is too small when it comes to eligibility verification.

Moreover, many applicants mistakenly think that doctors' signatures can be stamped rather than handwritten. The application explicitly states that a physician's signature cannot be a stamp or an electronic signature. This means those putting in their applications must ensure that the physician personally signs the form to avoid disqualification.

Lastly, some people fail to provide the necessary proof of identification for the disabled applicant. It is required to submit a copy of the New York State Driver’s License or ID card of the disabled person. Forgetting this crucial detail will lead to automatic denial of the application. Applicants must understand that these documents are essential for verifying identity and residency.

Documents used along the form

The Nassau Parking Application form is essential for obtaining a handicapped parking permit in Nassau County. In addition to this form, several other documents might be required or helpful during the application process. Below is a list of those commonly used forms and documents.

  • Proof of Residency: A document such as a utility bill or lease that confirms the applicant's address in Nassau County. This is necessary to verify eligibility.
  • Driver’s License or ID Card: A copy of the applicant’s New York State driver’s license or non-driver ID. This helps establish identity and is required for permit issuance.
  • Medical Certification Form: This may be a separate document that provides detailed medical information about the applicant's condition. It must be completed by a licensed physician.
  • Application Status Confirmation: A receipt or confirmation of submission can be helpful for tracking the status of the application.
  • Self-Addressed Envelope: Including a pre-paid envelope with the application can expedite the return of the permit once approved.
  • Temporary Permit Application: For those seeking a temporary permit, a different form may be required, specifically addressing temporary disabilities and the duration of the need.
  • Power of Attorney Documentation: If someone is applying on behalf of the applicant, a signed power of attorney may be needed to demonstrate authority in handling the application.
  • Verification of Disability Documents: Additional documentation such as blue badge registration or other related medical documents might be required to further verify the disability.
  • Financial Assistance Forms: Occasionally, proof of financial status may be needed, especially if applying for additional resources or benefits related to disability.
  • Renewal Application Form: If the applicant is renewing their permit, a specific form for renewal, not the original application, will be needed.

Having these documents ready can streamline the application process and improve the chances of a timely approval. Always ensure that all submitted materials are current and correctly filled out to avoid delays.

Similar forms

  • Disability Verification Form: This document requires personal information about the applicant and a medical professional's confirmation of the disability. It is similar to the Nassau Parking Application in that it validates the individual’s claim for assistance based on physical challenges.
  • Temporary Permit Application: Much like the Nassau application, this form is specifically for those needing a short-term solution due to a temporary disability. The process involves personal details and medical verification, ensuring that only eligible individuals receive the needed permit.
  • Accessible Parking Application: This application serves a similar purpose by allowing individuals with physical disabilities to seek special parking privileges. Both require comprehensive personal data and a medical certifying signature, emphasizing the need for proof of disability.
  • State Handicapped Parking Permit Application: As both forms aim to grant parking rights to disabled individuals, they share common elements like personal identification and medical verification. The state’s application mirrors the Nassau Parking Application by ensuring proper issuance to those meeting technological and physical standards.
  • Assistive Device Identification Form: This document also seeks to identify individuals requiring specific aids for mobility. Similar to the Nassau Parking Application, it asks for personal information and medical endorsement regarding the device's necessity for the applicant's mobility.
  • Veteran’s Disability Parking Application: Designed for veterans with disabilities, this form focuses on ensuring that those who served the country receive parking privileges. Much like the Nassau Application, it requires personal details along with medical documentation to justify the request.

Dos and Don'ts

When filling out the Nassau Parking Application form, here are nine important dos and don’ts to keep in mind:

  • Do ensure all personal information is accurate and complete.
  • Do not use a P.O. Box; provide a valid street address in Nassau County.
  • Do have a licensed medical doctor complete the medical certification section.
  • Do not submit forms signed by a chiropractor as they will not be accepted.
  • Do include a copy of the disabled applicant’s New York State ID or driver’s license.
  • Do not send copies or faxes of the application; originals are required.
  • Do sign the application clearly; stamped signatures are not valid.
  • Do not omit any required information; all sections must be filled out.
  • Do enclose a self-addressed envelope to expedite the permit issuance.

Misconceptions

Many people have misunderstood the Nassau Parking Application form. Here are five common misconceptions:

  • Only Drivers Can Apply: Many believe that only individuals who drive can apply for a handicapped parking permit. However, the application allows non-drivers, including children, to apply as long as the permit is issued in the name of the person with the disability.
  • P.O. Box Addresses Are Acceptable: It is a common belief that using a P.O. Box for the address on the application is sufficient. In reality, the application requires a physical street address within Nassau County.
  • Any Physician Can Certify the Application: Some people think that any medical professional can sign the medical certification. The form specifically requires a New York State licensed medical doctor for the certification process. Chiropractors are explicitly not accepted.
  • Faxed or Copied Applications Are Fine: Another misconception is that submitting a fax or a copied version of the application is permitted. In fact, submitting anything other than the original application will lead to an immediate denial.
  • It’s Easy to Get a Permit: Some applicants believe they can easily obtain a permit just by filling out the form. However, any false statement by the applicant or their physician can result in the refusal to issue a permit, making the process more rigorous than it appears.

Key takeaways

Key Takeaways for Filling Out the Nassau Parking Application Form:

  • Ensure you are a Nassau County resident. A valid street address is needed, as P.O. Boxes are not accepted.
  • The application must be filled out completely, with all questions answered. A licensed New York State medical doctor must complete the medical certification.
  • Only the person with the disability can be the applicant. Information on the form should relate specifically to this individual, even if they do not drive.
  • Provide the disabled person's New York State Drivers License Client ID number or NYS ID number. Include a copy of their ID, not the driver's ID if someone else will drive them.
  • Avoid sending copies or faxes as they will lead to an immediate denial of your application.
  • To speed up receiving your permit after approval, include a self-addressed envelope for the office to send the permit back.