The Arkansas 10 336 form is a document used to certify the eligibility of individuals with disabilities for special license plates or certificates. This form must be completed by a licensed physician or an organization that provides transportation for persons with disabilities. It ensures that the necessary information is collected for statistical purposes and helps facilitate access to parking privileges for those who need it.
The Arkansas 10 336 form serves as a crucial document for individuals seeking special license plates or certificates designed for persons with disabilities. This form is divided into two parts, catering to both licensed physicians and organizations that provide transportation services for individuals with disabilities. In Part 1, a licensed physician must certify the disability of the individual applying for the special license plate or certificate, indicating whether the disability is permanent or temporary. The physician is required to provide specific details about the individual’s condition, selecting from a list of qualifying disabilities that impact mobility. Part 2 is intended for organizations, allowing them to certify that they own or lease vehicles primarily used for transporting persons with disabilities. The form also emphasizes the importance of accurate information, as it is essential for statistical purposes and compliance with state regulations. Furthermore, it outlines the responsibilities and privileges associated with the use of special plates and certificates, including parking rights and the consequences of misuse. Understanding the requirements and implications of the Arkansas 10 336 form is vital for both applicants and their caregivers, ensuring that those in need receive the support they require.
The Arkansas 10 336 form is a certification document used to apply for a special license plate or certificate for individuals with disabilities. This form is essential for both licensed physicians and organizations that provide transportation services to those with disabilities. It ensures that individuals who qualify can obtain the necessary permits to access designated parking spaces and other benefits.
Part 1 of the Arkansas 10 336 form must be completed by a licensed physician when certifying an individual with a disability. This section requires the physician to provide their information, confirm the patient's disability status, and specify the nature of the disability by checking the appropriate boxes that correspond to various conditions.
In Part 1, the physician must provide their name, address, and the name and address of the person with a disability. They also need to indicate whether the disability is permanent or temporary and check the applicable conditions from a list. The physician's signature and date are also required to validate the certification.
If the applicant is an organization, Part 2 of the form must be completed. This section requires the organization's name, address, and Federal Employer Identification Number. The authorized official of the organization must certify that the organization owns or leases vehicles primarily used for transporting individuals with disabilities.
The information collected on the Arkansas 10 336 form is entered into a permanent record that allows for statistical retrieval of disability types. This helps the state to monitor and address the needs of individuals with disabilities more effectively.
Providing false information on the form, or assisting someone unqualified in obtaining a special plate or certificate, is considered a Class A misdemeanor. This can lead to legal penalties, including fines and potential criminal charges.
Special license plates or certificates must be used exclusively for transporting the individual for whom they were issued. The certificate should be displayed prominently on the vehicle, either on the inside rearview mirror or on the dashboard if no rearview mirror is present.
If a person with a special certificate or license plate moves to another state, they must surrender the certificate or plate to the nearest Revenue Office. In the unfortunate event of the holder's death, the special certificate or plate must be returned within thirty days to the Revenue Office.
The special certificate for permanently disabled individuals expires four years from the last day of the month in which it was issued. In contrast, a special temporary certificate is valid for three months from the last day of the month of issuance. Renewal does not require re-certification of the qualifying disability for the permanent certificate.
STATE OF ARKANSAS
LICENSED PHYSICIAN’S OR ORGANIZATION’S CERTIFICATION FOR ISSUANCE
OF A SPECIAL LICENSE PLATE OR CERTIFICATE FOR A PERSON WITH A DISABILITY
If a licensed physician certifying an individual, complete Part 1. If an organization providing transportation for persons with a disability with conditions in A through L below, complete Part 2.
Notice to Applicant: The department is required to enter into the permanent record disability types in a manner that will allow retrieval of such information for statistical use. The photo ID number or driver’s license number of the person with a disability is necessary to identify and retrieve these statistics.
PART 1: TO BE COMPLETED BY A LICENSED PHYSICIAN AND APPLICANT (UNLESS APPLICANT IS AN ORGANIZATION)
Name of Physician:
Address:
City State Zip:
Name of Person with Disability:
If Temporary Placard need Social Security Number, Driver’s
License Number or State Assigned Identification Number:
I hereby certify that the individual listed above is or has been a patient under my care and is disabled either permanently or temporarily as indicated below.
CIRCLE ONE:
PERMANENTLY
TEMPORARILY
Check the appropriate box or boxes A through L, which defines the patient’s condition(s).
(A) Cannot walk one hundred (100) feet without stopping to rest;
(B)
Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair, or
other assistive device;
(C)
Is restricted by lung disease to such an extent that the person’s forced respiratory expiratory volume for one (1) second,
when measured by spirometry, is less than one (1) liter, or the arterial oxygen tension is less than sixty (60) mm/hg on room
air at rest;
(D) Uses portable oxygen;
(E)
Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV
according to standards set by the American Heart Association;
(F)
Spinal cord injury;
(G)
Genetic ambulatory disorder;
(H)
An amputation;
(I)
Spina bifida;
(J)
Multiple Sclerosis;
(K)
Chronic heart disease;
(L)
Other:______________________________________________________________________________________________
If none of the conditions in A through L above applies, list the permanent medical condition that substantially impacts the person’s mobility.
Signature of Physician:
Date
PART 2: TO BE COMPLETED IF APPLICANT IS AN ORGANIZATION
Name of Organization:
Federal Employer Identification Number:
(M) This is to certify that the organization above owns or leases vehicles used primarily for transporting persons with disabilities as defined in items (A) through (L) in Part 1.
Signature of Authorized Organization Official:
IMPORTANT NOTICE ON BACK
10-336
10/07
APPLICANTS AND PERSONS DRIVING FOR APPLICANTS WHO REQUEST
A SPECIAL LICENSE PLATE OR SPECIAL CERTIFICATE FOR PERSONS WITH A DISABILITY
The following requirements are provided in accordance with Ark. Code Ann. §27-15-307(7).
•The privilege to park in spaces reserved for persons with disabilities shall be available only when the vehicle is being used to transport the person for whom the special plate or certificate was issued.
•Special certificates must be displayed on the inside rearview mirror, or on the dashboard, if the vehicle is of a type that does not have an inside rearview mirror.
•Any individual who provides false information to obtain a special plate or certificate, or assists an unqualified person in acquiring a special license plate or special certificate shall be deemed guilty of a Class A misdemeanor.
•Any person who abuses the privileges granted by a special license plate or certificate shall be deemed guilty of a Class A misdemeanor.
•Any unauthorized vehicle found to be parked in an area designated for the exclusive use of a person with a disability shall be subject to impoundment by the appropriate law enforcement agency. In addition to impoundment, the owner of the vehicle shall upon conviction be subject to fine of not less than one hundred dollars ($100) nor more than five hundred dollars ($500) for the first offense, nor less than two hundred fifty dollars ($250) nor more one thousand dollars ($1000) for the second and subsequent offense, plus applicable towing, impoundment, and related fees as well as court costs. Upon the second or subsequent conviction, the court shall suspend the driver’s license for up to six (6) months. The driver may apply to the Office of Driver Services of the Arkansas Department of Finance and Administration for a restricted license during the period of suspension.
•If a person to whom a special certificate or license plate has been issued moves to another state, the person shall surrender the special certificate or plate to the nearest Revenue Office.
•If a person to whom a special certificate or license plate has been issued dies, the special certificate or license plate shall be returned to the Revenue Office within thirty (30) days after the death of the person to whom the special certificate or plate was issued.
•The special certificate issued for the permanently disabled shall expire four (4) years from the last day of the month in which it was issued. The applicant shall not be required to obtain re-certification of his qualifying disability in order to renew his special certificate.
•The special temporary certificate shall expire three (3) months from the last day of the month in which it was issued.
Suspended Title Arkansas - Sign this to give permission for a replacement title request.
Arkansas 1086 - The Arkansas 1086 form contributes to the development of agriculture in the state.
A California Power of Attorney form is a legally binding document that allows you to designate someone to make financial or medical decisions on your behalf when you are unable to do so. This important tool ensures that your wishes are respected and that your affairs are managed by someone you trust. Understanding how this form works can empower you to make informed choices for your future. For more resources, you can check out the Templates and Guide.
Arkansas Real Estate Contract for Sale by Owner - The document includes a detailed description of the property being purchased, including its location.
When filling out the Arkansas 10 336 form, there are important dos and don'ts to keep in mind. This ensures a smooth process and avoids unnecessary delays.
Failing to provide the photo ID number or driver’s license number of the person with a disability, which is essential for record-keeping and statistical purposes.
Not completing the correct section of the form. Applicants must ensure they fill out Part 1 if they are an individual or Part 2 if they represent an organization.
Leaving out the name and address of the physician or organization, which is necessary for identification and verification.
Not circling the appropriate disability status, either permanently or temporarily, which is crucial for the application’s validity.
Failing to check the appropriate boxes (A through L) that describe the person's condition, which can lead to delays or denials in processing.
Providing inaccurate or incomplete information about the individual’s medical condition, which could result in legal consequences.
Not obtaining the necessary signature from the physician or authorized organization official, which is required for the certification to be valid.
Overlooking the expiration dates for special certificates, which can lead to penalties if not renewed in time.
Neglecting to display the special certificate properly in the vehicle, as required by law, which could result in fines.
Ignoring the legal implications of providing false information, which can result in a Class A misdemeanor charge.