The Arkansas 10 336 form is a certification document used by licensed physicians or organizations to request a special license plate or certificate for individuals with disabilities. This form is essential for identifying and documenting the mobility impairments of applicants, ensuring they receive the appropriate accommodations. If you or someone you know qualifies, take the first step by filling out the form below.
The Arkansas 10 336 form plays a vital role in facilitating the issuance of special license plates or certificates for individuals with disabilities. This form is designed to be completed by either a licensed physician or an organization that provides transportation services for persons with disabilities. It consists of two main parts: the first part requires a physician to certify the disability of an individual, while the second part is for organizations that own or lease vehicles specifically for transporting individuals with disabilities. The form captures essential information, such as the physician’s details, the patient's name and address, and a list of conditions that qualify for the special license plate or certificate. Conditions range from mobility impairments to severe respiratory issues, ensuring that a wide array of disabilities is recognized. Additionally, the form emphasizes the importance of accurate record-keeping for statistical purposes, necessitating the inclusion of identification numbers. Beyond its administrative function, the form also outlines the responsibilities and privileges associated with the special license plates and certificates, including parking regulations and penalties for misuse. This comprehensive approach not only aids in the identification of eligible individuals but also serves to protect the integrity of the program designed to assist those with disabilities.
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.
Filling out the Arkansas 10 336 form is an essential step for individuals or organizations seeking a special license plate or certificate for a person with a disability. After completing this form, it will be submitted to the appropriate department for processing. Ensure that all information is accurate and complete to avoid any delays in receiving the necessary documentation.
The Arkansas 10 336 form is used to certify that a person has a disability that qualifies them for a special license plate or certificate. This form can be completed by a licensed physician or an organization that provides transportation for individuals with disabilities. It helps ensure that those who truly need accessible parking can obtain the necessary permits.
Part 1 of the Arkansas 10 336 form must be completed by a licensed physician if the applicant is an individual. The physician must provide their information and certify that the individual has a disability that is either permanent or temporary. This section requires specific details about the person's condition to determine eligibility for a special license plate or certificate.
Organizations that provide transportation for persons with disabilities should complete Part 2 of the form. They need to provide their name, address, and Federal Employer Identification Number. Additionally, the authorized official of the organization must certify that they own or lease vehicles primarily used for transporting individuals with disabilities as defined in Part 1. This ensures that the organization is recognized for its role in assisting those in need.
Misuse of a special license plate or certificate can lead to serious consequences. If someone provides false information to obtain these privileges, they may face a Class A misdemeanor charge. Additionally, unauthorized vehicles parked in designated spaces can be impounded, and the owner may incur fines ranging from $100 to $1,000, depending on the number of offenses. Repeat offenders may also face a suspension of their driver's license for up to six months.
Not providing the correct photo ID number or driver’s license number of the person with a disability. This information is crucial for tracking and statistical purposes.
Failing to circle whether the disability is permanent or temporary. This choice impacts the type of certification issued.
Leaving out the signature of the physician. Without this signature, the form cannot be processed.
Not checking the appropriate boxes (A through L) that define the patient’s condition. Omitting this step can lead to delays in processing.
Providing incorrect or incomplete address information for both the physician and the applicant. Accurate addresses are necessary for communication.
For organizations, failing to include the Federal Employer Identification Number can result in rejection of the application.
Not including any additional medical conditions that may impact mobility if none of the listed conditions apply. This information is important for proper evaluation.
Ignoring the requirements for displaying the special certificate or license plate in the vehicle. Proper display is essential for legal use.
Providing false information or assisting an unqualified person in obtaining a special plate or certificate. This action is considered a Class A misdemeanor.
The Arkansas 10 336 form is essential for individuals with disabilities seeking special license plates or certificates. Alongside this form, several other documents may be required to support the application process. Below is a list of these documents, each serving a specific purpose.
Gathering these documents can streamline the application process for a special license plate or certificate in Arkansas. Ensuring that all necessary paperwork is complete can help avoid delays and complications down the line.
The Arkansas 10 336 form is similar to the Application for Disabled Person Parking Permit in several states. This document requires a licensed physician to verify the applicant's disability. Both forms aim to provide individuals with disabilities access to designated parking spaces. The physician must confirm the applicant's condition, ensuring that only those who truly need assistance receive the permit. This helps prevent misuse and ensures that parking resources are available for those who genuinely require them.
Another comparable document is the Medical Certification for Special Parking Privileges, often used in various jurisdictions. Like the Arkansas 10 336 form, this certification requires a medical professional's endorsement to confirm the applicant's disability status. The intent is the same: to facilitate parking access for individuals with mobility challenges. Both forms include a list of qualifying conditions that must be checked off by the certifying physician, streamlining the approval process for applicants.
The Americans with Disabilities Act (ADA) Paratransit Eligibility Certification is another document that shares similarities with the Arkansas 10 336 form. This certification is designed to determine eligibility for paratransit services for individuals with disabilities. Both forms require a physician’s verification of the applicant's condition. The ADA certification process, like the Arkansas form, aims to ensure that individuals who genuinely need transportation assistance receive it while maintaining a system that prevents fraud.
The Disability Parking Application used in many states also aligns closely with the Arkansas 10 336 form. This application requires medical documentation to support the need for a disability parking permit. Both documents focus on confirming the applicant's disability through a physician's signature. They serve the same purpose of providing necessary accommodations to individuals with disabilities, ensuring they have access to convenient parking options.
Additionally, the State Disability Identification Card Application is similar in its purpose and requirements. This application requests medical verification of a disability to issue an identification card that provides access to various benefits. Like the Arkansas 10 336 form, it emphasizes the importance of having a licensed medical professional certify the disability. Both forms aim to provide individuals with disabilities the recognition and resources they need to navigate daily life more easily.
Lastly, the Special Needs Vehicle Registration Form is comparable to the Arkansas 10 336 form. This form requires information about the applicant's disability and the vehicle intended for use. Both documents necessitate a physician's confirmation of the disability status. They aim to ensure that individuals with special needs can register their vehicles in a way that reflects their requirements, allowing for appropriate accommodations in transportation and parking.
When filling out the Arkansas 10 336 form, there are important considerations to keep in mind. Here are four things you should and shouldn't do:
Misconceptions about the Arkansas 10 336 form can lead to confusion for applicants and healthcare providers alike. Here are five common misconceptions, along with clarifications:
This is not true. The form accommodates both permanent and temporary disabilities. Applicants can indicate whether the disability is temporary by selecting the appropriate option.
While organizations can apply, they still need to certify that they own or lease vehicles for transporting persons with disabilities. This requires the signature of an authorized official, not a physician.
This is incorrect. The privilege to park in designated spaces is only available when the vehicle is used to transport the person for whom the plate was issued.
In fact, there are serious consequences. Providing false information or abusing the privileges can lead to misdemeanor charges and fines ranging from $100 to $1,000.
This is a common misunderstanding. The special certificate for permanent disabilities expires four years after issuance, while the temporary certificate is valid for only three months.
When filling out the Arkansas 10 336 form, it is essential to understand the requirements and processes involved. Here are ten key takeaways: