Fillable Form Reg 195

What is Form REG 195?

Form REG 195, Application for Disabled Person Placard or Plates, is a document used to apply for a disabled person (DP) parking placard or license plate in California.

The types of disabled person parking placards or license plates include:

To obtain a disabled person parking placard or license plate, you must:

How to fill out Form REG 195?

Complete Form REG 195 legibly. Otherwise, the California DMV will return your Form REG 195 and may delay your application.

SECTION 1 — APPLICANT OR ORGANIZATION INFORMATION

Enter your information. The California DMV requires you to provide a copy of proof of your name and birthdate to prove your identity.

TRUE FULL NAME (LAST, FIRST, MIDDLE OR ORGANIZATION NAME)

Enter your name.

DATE OF BIRTH (FOR INDIVIDUALS ONLY

Enter your date of birth.

PHYSICAL ADDRESS (INCLUDE ST., AVE., RD., CT., ETC.)

Enter the street, avenue, road, or court where you live.

APT./SPACE/STE.#

Enter the apartment, space, or suite number where you live.

CITY

Enter the city where you live.

COUNTY

Enter the county where you live.

STATE

Enter the state where you live.

ZIP CODE

Enter the ZIP code where you live.

MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL ADDRESS ABOVE)

Enter the street, avenue, road, or court of your mailing address.

APT./SPACE/STE.#

Enter the apartment, space, or suite number of your mailing address.

CITY

Enter the city of your mailing address.

COUNTY

Enter the county of your mailing address.

STATE

Enter the state of your mailing address.

ZIP CODE

Enter the ZIP code of your mailing address.

DAYTIME TELEPHONE NUMBER

Enter your daytime telephone number.

DRIVER LICENSE/ID CARD NUMBER (FOR INDIVIDUALS ONLY)

Enter your driver’s license or identification card number.

SECTION 2 — TYPE OF DISABLED PERSON PARKING PLACARD(S) OR LICENSE PLATES (Check all that apply.)

Mark the type of disabled person (DP) parking placards or license plates you want to obtain. You may choose from the following:

Have you ever been issued a DP License Plate, Disabled Veteran License Plate, or a Permanent DP parking placard in California?

Mark "Yes," if you have been issued a DP License Plate, Disabled Veteran License Plate, or a Permanent DP parking placard in California. If not, mark "No."

If yes, the license plate or DP parking placard number is

If you marked "Yes" to the question above, enter the license plate or DP parking placard number of the issued DP License Plate, Disabled Veteran License Plate, or a Permanent DP parking placard.

SECTION 3 — DISABLED PERSON LICENSE PLATE APPLICANTS ONLY: VEHICLE INFORMATION

This section is for disabled person license plate applicants only. If you marked "Disabled Person License Plates (No Fee)" or "Disabled Person License Plate Reassignment" in section 2, you may fill out this part.

LICENSE PLATE NUMBER

Enter your vehicle license plate number.

VEHICLE IDENTIFICATION NUMBER (VIN)

Enter your Vehicle Identification Number (VIN).

VEHICLE MAKE

Enter your vehicle make.

VEHICLE YEAR

Enter your vehicle year.

Commercial Vehicles – Weight Fee Exemption. I am requesting an exemption from weight fees for the vehicle described above. It weighs less than 8,001 pounds unladen. I understand that this exemption may be used for ONE commercial vehicle only and I do not have this exemption for any other vehicles I own.

Mark "Yes" if you wish to request an exemption from weight fees for the vehicle you described above. If not, mark "No."

SECTION 4 — APPLICANT OR ORGANIZATION REPRESENTATIVE’S CERTIFICATION AND SIGNATURE

Provide necessary information to certify your Form REG 195 claims.

By signing and dating your Form REG 195, you certify that you are a disabled person or an authorized representative of an organization involved in the transportation of disabled persons. You also certify that all you understand and take the responsibility for the use of the disabled person placard and or license plates that will be issued to you.

SIGNATURE OF APPLICANT OR ORGANIZATION AUTHORIZED REPRESENTATIVE

Enter your signature.

DATE

Enter the date when you signed Form REG 195.

SECTION 5 — AUTHORIZED MEDICAL PROVIDER’S INFORMATION

This section is for the applicant's authorized medical provider's use only.

MEDICAL PROVIDER’S NAME (LAST, FIRST, MIDDLE)

Enter your name.

MEDICAL LICENSE NUMBER

Enter your medical license number.

MEDICAL PROVIDER’S ADDRESS (INCLUDE ST. AVE, RD., CT, ETC.)

Enter the street, avenue, road, and court where you live or operate your business.

ROOM/SUITE NUMBER

Enter the room or suite number where you live or operate your business.

CITY

Enter the city where you live or operate your business.

COUNTY

Enter the county where you live or operate your business.

STATE

Enter the state where you live or operate your business.

ZIP CODE

Enter the ZIP code where you live or operate your business.

DAYTIME TELEPHONE NUMBER

Enter your daytime telephone number.

SECTION 6 — MEDICAL PROVIDER’S CERTIFICATION OF DISABILITY

This section is for the applicant's authorized medical provider's use only.

My patient suffers from the condition(s) below and, pursuant to CVC §295.5, is eligible for a:

Enter the applicant's name.

PERMANENT DP PARKING PLACARD OR LICENSE PLATE

Mark the box if the applicant is eligible for a permanent DP parking placard or license plate.

TEMPORARY DP PARKING PLACARD

Mark the box if the applicant is eligible for a temporary DP parking placard. Then, enter the month, day, and year of duration. The duration must not exceed six months.

TRAVEL DP PARKING PLACARD

Mark the box if the applicant is eligible for a travel DP parking placard. Then, enter the month, day, and year of duration. The duration may not exceed 30 days for a California resident and 90 days for a non-resident.

1. Central visual acuity does not exceed 20/200 in the better eye, with corrective lenses, as measured by the Snellen test, or visual acuity that is greater than 20/200, but with a limitation in the field of vision such that the widest diameter of the visual field subtends an angle not greater than 20 degrees.

Mark the box if the applicant's central visual acuity does not exceed 20/200 in the better eye, with corrective lenses, as measured by the Snellen test, or visual acuity that is greater than 20/200, but with a limitation in the field of vision such that the widest diameter of the visual field subtends an angle not greater than 20 degrees. If not, leave it blank.

2. A cardiovascular disease to the extent that the person’s functional limitations are classified in severity as class III or class IV based upon standards accepted by the American Heart Association.

Mark the box if the applicant has a cardiovascular disease to the extent that the person’s functional limitations are classified in severity as class III or class IV based upon standards accepted by the American Heart Association. If not, leave it blank.

3. A lung disease to the extent that forced (respiratory) expiratory volume for one second when measured by spirometry is less than one liter or arterial oxygen tension (pO2) is less than 60 mm/Hg on room air while the person is at rest.

Mark the box if the applicant has a lung disease to the extent that forced (respiratory) expiratory volume for one second when measured by spirometry is less than one liter or arterial oxygen tension (pO2) is less than 60 mm/Hg on room air while the person is at rest. If not, leave it blank.

4. A diagnosed disease or disorder which substantially impairs or interferes with mobility due to (complete Section 6A):

Mark the box if the applicant has a diagnosed disease or disorder which substantially impairs or interferes with mobility due to a certain condition. Then, provide descriptions of the condition in section 6A later. If not, leave it blank.

5. A severe disability in which the person is unable to move without the aid of an assistive device, which is due to (complete Section 6A):

Mark the box if the applicant has a severe disability in which the person is unable to move without the aid of an assistive device, which is due to a certain condition. Then, provide descriptions of the condition in section 6A later. If not, leave it blank.

6. A significant limitation in the use of lower extremities due to (complete Section 6A):

Mark the box if the applicant has a significant limitation in the use of lower extremities due to a certain condition. Then, provide descriptions of the condition in section 6A later. If not, leave it blank.

7. The loss, or loss of the use of one or more lower extremities. Loss of use due to (complete Section 6A):

Mark the box if the applicant has the loss or loss of the use of one or lower extremities. Then, provide the cause of loss of use in section 6A later. If not, leave it blank.

8. The loss, or loss of the use of, both hands. Loss of use due to (complete Section 6A):

Mark the box if the applicant has the loss, or loss of the use of, both hands. Then, provide the cause of loss of use in section 6A later. If not, leave it blank.

SECTION 6A — DESCRIPTION OF ILLNESS OR DISABILITY AS NOTED IN 4-8

Enter the supplementary details for the conditions in section 6, numbers 4 through 8.

I certify that I am an authorized and currently state licensed:

Mark your area of specialization. You may choose from the following:

MEDICAL PROVIDER’S SIGNATURE

Enter your signature.

DATE

Enter the date when you signed Form REG 195.

DMV USE ONLY

Do not enter anything. This section is for the California DMV's use only.

How to file Form REG 195?

You may submit your Form REG 195 and other documents such as your identification by mail or in person.

If you want to submit your Form REG 195 in person, you may go to the California Department of Motor Vehicle office.

To mail your Form REG 195, you may use the mailing address:

DMV Placard

P.O. Box 932345 M/S D238

Sacramento, CA 94232-3450