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Currently electronic submissions of this form cannot be processed. Please print the application and submit to the applicable county treasurer's office with any necessary fees.

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Permanent Portable Permit (Permanent permits must be renewed every five years. A doctor certification is not required upon renewal.)
Renewal of Permanent Portable Permit (This permit is renewable 90 days prior to expiration date. A doctor certification is not required upon renewal.)
Two Portable Permits Requested (Permanent permits only)
A Second Portable Permit Requested (Permanent permits only)
Temporary Portable Permit (Issued for a temporary disability not to exceed twelve months.)
Renewal of Temporary Permit (See page two for medical certification.)
Vehicle
Motorcycle
Medically Certified Applicant (print name):
For Applicant By (Print name and relationship):
Cannot walk 200 feet without stopping to rest
Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, a prosthetic device, a wheelchair, or another assertive device
Is restricted by lung disease to such an extent that the person's forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than on liter, or the arterial oxygen tension is less than 60 mm/hg on room air at rest
Uses portable oxygen
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 the American Heart Association leaflet. The functional and therapeutic classifications of patients with diseases of the heart, "in print on June 1st, 1990."
Is severely limited in ability to walk due to an arthritic, neurological, or orthopedic condition.
Physical disability is permanent
Physical disability is temporary Portable permit can be issued for a maximum length of one year
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