Medical Evaluation Report
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Disabled Parking Placard (must also submit a completed Disabled Parking Placard Application VD-120) Disabled Parking Plate (must also submit a completed Registration, Tax and Title Application VD-119) Parking Placard Applicants: The Information In This Medical May Be Considered In Determining Your License Status SECTION A - To Be Completed By Applicant Patient’s Name: Street / Road / Box Number Patient’s Mailing Address: City / State / Zip Code Physical Address – If Different From Mailing Address Gender: Mailing Address Physical Address Check If The Above Is A Change To Your: Date Of Birth Social Security Number VT Driver License/Id Number If This Is A Name Change, List Former Name: I certify that the information contained above is true, complete and correct to the best of my knowledge..
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