Form PA-3 Instruction Sheet
PERSON WITH A DISABILITY PARKING PERMIT APPLICATION FORM
INSTRUCTION SHEET (FORM PA-3)
SIDE 1 – TO BE COMPLETED BY APPLICANT
1. APPLICANT INFORMATION. Print or type your name, beginning with your first name, middle initial, then last
name. Only include a suffix (Jr., Sr., III, etc.) if applicable.
2. PHONE NUMBER. Print your telephone number, including the area code. If you do not have a telephone
number, write “NONE.”
3. EMAIL ADDRESS. Enter your email address if you have one. This is optional. DCAB will use it ONLY to contact
you for parking program purposes.
4. DATE OF BIRTH. Print the month, day and year. Example: If your date of birth is June 30, 1965, you
would print 06/30/1965.
5. HEIGHT. Print your height in feet and inches.
6. WEIGHT. Print your weight in pounds.
7. GENDER. Mark the box for either Male or Female.
8. MAILING ADDRESS. Print your mailing address.
9. INDICATE THE COUNTY WHERE YOU LIVE. Answer only if you live in Hawaii. Mark the box next to the
county where you reside. Mark one box only.
10. PARKING PLACARD REQUEST. Mark the box next to the type of placard you are requesting.
• First time application. Mark this box if this is the first time that you are applying for a temporary (red)
placard, long term (blue) placard, Disability Paid Parking Exemption Permit/DPPEP (green) placard, or
special license plates. A temporary (red) placard will be valid for no more than 6 months. There is a $12 fee
for a temporary (red) placard. There is no fee for a first time long term (blue) placard or a first time DPPEP
(green) placard.
• Second placard. Mark this box if you want a second temporary (red) placard. A second temporary (red)
placard is an additional placard that has the same expiration date as its companion placard. There is a $12
fee for a second temporary (red) placard.
• Renewing placard. Mark this box to renew your temporary (red) placard, long term (blue) placard, or
Disability Paid Parking Exemption Permit/DPPEP (green) placard. You may apply up to 60 days before it
expires. Print the placard number of your expiring or expired placard(s) in the space provided. Check your
blue I.D. card for your placard number(s). If you currently have two temporary (red)
placards and want two
renewal temporary (red) placards, enter the placard number of each expiring or expired placard in the
spaces provided. There is a $12 fee for renewing each temporary (red) placard. There is no fee to renew a
long term (blue) placard or Disability Paid Parking Exemption Permit/DPPEP (green) placard. YOU MUST
ALSO HAVE YOUR DISABILITY RECERTIFIED BY A LICENSED PRACTICING PHYSICIAN/ADVANCED
PRACTICE REGISTERED NURSE (APRN).
• Replacing a confiscated, lost, stolen, or mutilated temporary (red) placard or long term (blue) placard.
Mark this box if your temporary (red) placard or long term (blue) placard was confiscated, lost, stolen, or
mutilated and is still valid. Print the placard number(s) in the space provided. Check your blue I.D. card for
the placard number(s). There is a $12 fee for replacing a confiscated, lost, or stolen temporary (red) placard
or long term (blue) placard. There is no fee for replacing a mutilated placard, but you must bring in its
remaining parts, otherwise, it will be treated as replacing a lost placard and a $12 fee will apply. Side 2 of
the form should be left blank.
• Replacing a confiscated, lost, or stolen Disability Paid Parking Exemption Permit/DPPEP (green)
placard. Mark this box if your DPPEP (green) placard was confiscated, lost, or stolen and is still valid. Print
the placard number in the space provided. Check your blue I.D. card for the placard number. The
replacement fees are as follows: first replacement $30, second replacement $60, third replacement $90,
and any subsequent replacement $120. Side 2 of the form should be left blank.
• Replacing a
mutilated Disability Paid Parking Exemption Permit/DPPEP (green) placard. There is no fee
for replacing a mutilated DPPEP (green) placard that is still valid. You must mail in its remaining parts,
otherwise, it will be treated as replacing a lost placard and a fee will apply. Side 2 of the form should be left
blank.
11. SPECIAL LICENSE PLATES REQUEST. Mark only if requesting Special License Plates. You must provide
information where indicated. You may obtain one set of plates and one long term (blue) placard or one Disability
Paid Parking Exemption Permit/DPPEP (green) placard.
12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION. Read the information
carefully. This is your statement that you understand the terms of using the placard or special license plates.
Sign and date the statement. If you are unable to sign due to your disability, your authorized representative may
sign on your behalf.