The Arkansas 10 336 form is a crucial document that certifies 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. Understanding the requirements and processes involved in this form is essential for ensuring that individuals receive the support they need.
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When filling out the Arkansas 10 336 form, it’s crucial to follow specific guidelines to ensure accuracy and compliance. Here are seven essential dos and don’ts to keep in mind:
By adhering to these guidelines, applicants can help facilitate a smoother process in obtaining the special license plate or certificate for persons with disabilities.
The Arkansas 10 336 form is a certification document used to apply for a special license plate or certificate for individuals with disabilities. It requires a licensed physician or an organization to certify the disability of the applicant, ensuring they qualify for the special privileges associated with these plates or certificates.
Part 1 of the form must be completed by a licensed physician if the applicant is an individual. This section includes details about the physician, the person with a disability, and a certification of the individual’s condition.
In Part 1, the following information is needed:
If the applicant is an organization, Part 2 must be completed. This section requires the organization’s name, address, and Federal Employer Identification Number. The authorized official must certify that the organization owns or leases vehicles primarily used for transporting persons with disabilities.
Providing false information on the Arkansas 10 336 form is considered a Class A misdemeanor. This includes assisting someone unqualified in obtaining a special plate or certificate. Legal consequences may include fines and potential criminal charges.
The special certificate must be displayed prominently. It should be placed on the inside rearview mirror or on the dashboard if the vehicle does not have an inside rearview mirror. This ensures visibility for enforcement purposes.
If a person with a special certificate or license plate moves to another state, they must surrender the special certificate or plate to the nearest Revenue Office. This is important for maintaining accurate records and compliance with state regulations.
The special certificate issued for permanent disabilities expires four years from the last day of the month in which it was issued. However, applicants do not need to undergo re-certification to renew this certificate.
A special temporary certificate expires three months from the last day of the month in which it was issued. It is crucial to keep track of this expiration to avoid any issues with parking privileges.
Abusing the privileges granted by a special license plate or certificate is also a Class A misdemeanor. Penalties may include fines ranging from $100 to $500 for the first offense and up to $1,000 for subsequent offenses. Additionally, unauthorized vehicles parked in designated spaces may be impounded.
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.