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Mobility Parking Scheme Application (MPS)

Mobility Parking Scheme Application (MPS)
Mobility Parking Scheme Application (MPS)

Individual and Temporary Permits

For more information in conjunction with this application please see:

the Mobility Parking Scheme (MPS) brochure, orinformation in conjunction with this application please see: visit www.rta.nsw.gov.au Customer number Attachments

visit www.rta.nsw.gov.auplease see: the Mobility Parking Scheme (MPS) brochure, or Customer number Attachments Important information Proof

Customer number

Attachments

Important information

Proof of identity

You or your representative must fill in the application form before seeing your medical doctor. The medical information in this application will be used for the administration of the MPS and where appropriate for the Driver Licensing Scheme. The RTA has

person applying for, renewing or replacing a MPS permit is

required to produce acceptable proof of their identity, such as a driver licence. Other acceptable identification documents are shown in List 1 and List 2 in the RTA brochure, How to prove who you are available at any RTA motor registry. Applicants may show one document each from List 1 and List 2. Alternatively, two List 2 documents, such as a current Medicare card or Pensioner Concession card, are acceptable. Further information can also be obtained from the RTA on 13 22 13 or the RTA website at www.rta.nsw.gov.au/licensing

A

Fees

a

responsibility to ensure that all NSW licence holders are

medically fit to drive. If you hold a driver licence and the RTA has not been notified of any medical condition, you will need to have your doctor complete Section 3 (Medical Report) of this application. The medical information will be used to verify your

medical fitness to drive. In the event that any medical practitioner recommends restrictions in respect of your driver licence or certifies that you are medically unfit to drive, this may result in restrictions being placed on your driver licence or the suspension

of

your driver licence. Section 3 is not required to be completed if

A

fee is required for the issue of an Individual or Temporary MPS

the application is for a temporary permit issued for the first time or where a previously held temporary permit has already expired.

permit to non-pensioners. Permits are free for pensioners. Proof of the concession is required and must be validated online. For information on current fees payable please visit www.rta.nsw,gov.au or call the RTA on 13 22 13.

Who is eligible?

To

be eligible for a MPS permit, a person must be unable to walk

 

because of permanent or temporary loss of the use of one or both legs or other permanent medical or physical condition, or whose physical condition is detrimentally affected as a result of walking 100 metres, or who requires the use of crutches, a walking frame, callipers, scooter, wheelchair, or other similar mobility aid. Permits are also available to people who are permanently blind.

Applicants that do not meet the eligibility criteria will not be issued

Privacy statement

The Roads and Traffic Authority (RTA) is collecting your personal and health information for your MPS application and to verify your fitness to drive and may retain and use it for driver licensing, motor vehicle and road transport or safety purposes. The RTA is subject to the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002.

The RTA is entitled to obtain your personal information under the Road Transport (Safety and Traffic Management) Regulation 1999 and may refuse your application if you do not provide it. The RTA may disclose your personal information:

to other driver licensing and vehicle registration agencies,Regulation 1999 and may refuse your application if you do not provide it. The RTA may

a

The minimum age for an applicant for a MPS permit is 3 years old.

permit.

If

you are required to have your doctor complete both medical

sections of this form it may be necessary to arrange an extra consultation or an extended consultation. Please note that you are responsible for any fees payable to the doctor for the consultation.

Photo requirements

to assess your application or verify the information you provide and,Photo requirements

Nearly all motor registries have disabled access and if necessary

for inquiries about motor accidents.Nearly all motor registries have disabled access and if necessary

an

appointment can be made with your local motor registry for a

convenient time to have a photograph taken. Individual and Temporary MPS permits include a photo of the permit holder, with exception of permits for people younger than 16 years of age. In other cases, exemptions from having a photo will be granted only if the applicant:

Additionally, where you provide personal information concerning the registration of a vehicle we may disclose that;

to confirm any compulsory insurance is currentthe registration of a vehicle we may disclose that; to anyone proposing to acquire an interest

to anyone proposing to acquire an interest in your vehicle,that; to confirm any compulsory insurance is current has a significant facial disfigurement, or in respect

has a significant facial disfigurement, orin respect of inquiries relating to stolen or abandoned vehicles, and

in respect of inquiries relating to stolen or abandoned vehicles, andhas a significant facial disfigurement, or

cannot meet standard RTA photo requirements of full frontal face image due to inadequate muscular control, orto any joint registered operator of your vehicle.

to any joint registered operator of your vehicle.cannot meet standard RTA photo requirements of full frontal face image due to inadequate muscular control,

is mostly bedridden because of advanced age or terminal illness, orThe RTA may disclose your health information to assess your application or to verify it.

The RTA may disclose your health information to assess your application or to verify it.

has a severe mental and/or physical disability that prevents them from attending a motor registry without significant inconvenience and/or embarrassment, orhas their mobility severely restricted by medical equipment.

has their mobility severely restricted by medical equipment.disability that prevents them from attending a motor registry without significant inconvenience and/or embarrassment, or

Otherwise the RTA will not disclose your personal information without your consent unless authorised by law.

Your personal and health information will be held by the RTA at 101 Miller Street, North Sydney NSW 2060 and you can contact the RTA to request access or correct it.

Under clause 159 of the Road Transport (Safety and Traffic Management) Regulation 1999, penalties apply for making false or misleading information.

Applying for an exemption

Applications for an exemption must be in writing, and accompanied by a completed application form with a supporting letter from a medical doctor and sent to:

The Manager, Customer Liaison & Data Management, RTA, P.O. Box 3035, Parramatta, NSW 2124.

 

If approved, a letter of exemption will be issued for presentation at

a motor registry.

Roads and Traffic Authority

ABN 64 480 155 255

www.rta.nsw.gov.au

13 22 13

Individual and Temporary Permits

Mobility Parking Scheme Application (MPS)

SECTION 1

1. Application details

Type of MPS permit needed

Individual

Individual Temporary

Temporary

Individual Temporary

Type of Application

 

New

New Renewal

Renewal

New Renewal

Replacement

Replacement specify details below
Replacement specify details below

specify details below

Lost

Confiscated

DamagedLost Confiscated Changed details including appearance Stolen Defaced Non receipt of permit Please complete

Changed details including appearanceLost Confiscated Damaged Stolen Defaced Non receipt of permit Please complete application including Q7 if applicable

StolenLost Confiscated Damaged Changed details including appearance Defaced Non receipt of permit Please complete

DefacedNon receipt of permit

Defaced

Non receiptof permit

of permit

Non receipt of permit

Please complete application including Q7 if applicable

2. Details for Individual or Temporary MPS permit

Surname of applicant

for Individual or Temporary MPS permit Surname of applicant Given names Residential address   Postcode

Given names

Residential address

 

Postcode

Date of birth

Customer no.(if known)

Day

/

Month

/

Year

 

Sex

male

Sex male female

female

Sex male female

3. Do you hold a current or suspended NSW licence?

No

No now go to 5. Licence number
No now go to 5. Licence number

now go to 5.

Licence number

Yes

Yes  
Yes  
 

Licence class

Expiry date

number Yes   Licence class Expiry date Day / Month / Year 4 . Is your

Day

/

Month

/

Year

4. Is your licence subject to medical review by the RTA?

(you can check this by calling the Contact Centre on 13 22 13)

No

No

Yes

Yes

If you ticked Yes for question 3 and No for question 4, your doctor will need to complete Section 3 (Medical Report) of this application. See Important Information on page 1 of this form.

See Important Information on page 1 of this form. 5. Declaration by applicant I Signature of

5.

Declaration by applicant

I

Signature of applicant

Date

Day

/

Month

/

Year

6.

 

I

out in the Conditions of Use.

I

Date

Day

/

Month

/

Year

7.

 

I

confiscated.

Date

Day

/ /

Month

Year

I confiscated. Date Day / / Month Year ***Please read important Privacy Statement and warning on
I confiscated. Date Day / / Month Year ***Please read important Privacy Statement and warning on
I confiscated. Date Day / / Month Year ***Please read important Privacy Statement and warning on

***Please read important Privacy Statement and warning on page 1 of this form.

declare that the details in this application are true and

complete and that any MPS permit issued as a result of this application, will only be used as set out in the Conditions of Use. I am aware that information provided in this application is

used for the MPS and Driver Licensing Scheme.

application is used for the MPS and Driver Licensing Scheme. Complete the declaration at 7 if

Complete the declaration at 7 if you are unable to return your current permit

Declaration by applicant's representative

***Please read important Privacy Statement and warning on page 1 of this form.

declare that the details in this application are true and

complete and that the applicant is aware that any MPS permit issued as a result of this application is only to be used as set

understand that my "personal information" is being collected as the representative of the applicant for the MPS permit.

Name of applicant's representative (please print)

Name of applicant's representative (please print) Signature of applicant's representative Declaration for

Signature of applicant's representative

(please print) Signature of applicant's representative Declaration for non-return of permits This declaration must

Declaration for non-return of permits

This declaration must be signed if you are unable to return the current permit as required.

declare that the MPS permit to be returned to the RTA is not

available because it is lost, stolen, damaged, non receipt or

Signature of applicant or representative

to the RTA is not available because it is lost, stolen, damaged, non receipt or Signature

Office use RTA Motor Registry / Agency

Proof of Identity Record Stand alone or primary proof

Secondary proof

Record Stand alone or primary proof Secondary proof D o c u m e n t
Record Stand alone or primary proof Secondary proof D o c u m e n t

Document number

Secondary proof D o c u m e n t n u m b e r

Secondary proof issue or E/Date

e n t n u m b e r Secondary proof issue or E/Date Signature of

Signature of registry officer or agent

proof issue or E/Date Signature of registry officer or agent Staff number or ID Date Day

Staff number or ID

Signature of registry officer or agent Staff number or ID Date Day / Month / Year

Date

Day

/

Month

/

Year

SECTION 2 SECTION 3 Medical Report To be completed by a registered medical practitioner. Medical
SECTION 2
SECTION 3
Medical Report
To be completed by a registered medical practitioner.
Medical Certificate
Please ensure that the applicant has filled in all personal
details in Section 1 before signing the declaration below.
The MPS is designed to maintain the independence of people with
mobility disability. Applicants that do not meet the eligibility criteria on
page 1 must not be certified as eligible for a permit. It is important that
only people with medical conditions that severely affect their mobility are
certified as meeting the scheme's eligibility criteria.
Name of applicant
Complete this section if the applicant has ticked Yes for Q3 in
Section 1 (holds a NSW licence) and No in Q4 in Section 1(not
subject to medical review). See Important Information shown on
page 1 of this form.
This section is required to determine if the applicant is medically
fit to drive.
Please complete this part in conjunction with the current
guidelines 'Assessing Fitness to Drive' for the class of licence
held (see Q3 in Section 1). The current guidelines can be found at
www.austroads.com.au
Where medical fitness cannot be determined, you should
refer the patient to an appropriate specialist.
The completed medical form can be returned to the patient.
Date of birth
1. History
/
/
How long have you treated this patient?
Day
Month
Year
Years
Months
I certify that I have examined the applicant shown above in
this form and the applicant's condition is:
2. Vision
VISION STANDARDS
One of the following clinically recognisable disabilities:
Paraplegia
Chromosomal or syndromic
conditions
Car, Rider and Light Rigid Drivers.
The criteria for an unconditional licence are NOT met
-
Quadriplegia
Neuro degenerative disorder
if the person's visual acuity in the better eye or with both
eyes together is worse than 6/12
Leg amputation
Neuro muscular disorder
Heavy Vehicles/Commercial Vehicles
The criteria for an unconditional licence are NOT met
Motor Neuron disease
Blindness
Cerebral palsy
- if the person's visual acuity is worse than 6/9 in the better
eye; or
- if the person's visual acuity is worse than 6/18 in either eye.
OR another non-clinically recognisable disability that meets
the MPS eligibility criteria
See 'Assessing Fitness to Drive' for more information.
(please specify)
Are glasses/lenses worn (distance)?
No
Yes
Visual acuity (distance)
R
L
Together
Is the condition temporary?
Yes
No
Uncorrected
6/
6/
6/
If temporary, give period of disability
months
With glasses
6/
6/
6/
(no more than 6 months)
Fields of vision
Normal
Abnormal
Declaration by the registered medical practitioner
Double vision
No
Yes
***Please read important Privacy Statement and warning on page 1 of
this form.
I declare that the details in this application are true and complete. I
understand that my "personal information" is being collected for
confirmation of the MPS Application Medical Certificate.
Poor night vision
No
Yes
An opthalmologist or optometrist can complete this section
if you wish.
I certify that today I have examined the person shown as the
applicant for a MPS permit and this person meets the eligibility
criteria for a MPS permit as shown on the front page of this form.
Name
Signature
Practitioner's name (please print)
3.
Cardio-Vascular Condition
No
Yes
If No, proceed to the next question.If Yes complete the following
*
Acute myocardial infarct
No
Yes
Business address
*
Angioplasty
No
Yes
*
Angina
No
Yes
Postcode
* Refer to Guidelines - Heavy Vehicle Licencees Only
Provider number
Office telephone number
Stress test
Ejection Fraction %
-ve
+ve
Cardiomyopathy
No
Yes
Signature
CABG
No
Yes
Hypertension/Hypotension
No
Yes
Date
Recurrent / persistent arrhythmia
No
Yes
/
/
Cardiac pacemaker
No
Yes
Day
Month
Year
Aneurysm (site)
No
Yes
Defibrillator
No
Yes

4. Diabetes

 

No

  No Yes

Yes

  No Yes

Tablets

InsulinTablets

Tablets Insulin
 

No

Yes  No

  No Yes
 

No

Yes  No

  No Yes
 

No

Yes  No

  No Yes

If No proceed to the next question. If Yes complete the following.

Controlled by:

Compliant with medication Hypoglycaemic awareness

(date of last episode)

End organ effects

5. Musculo-Skeletal Condition

eg degenerative or painful joints, arthritis, loss of limbs/digits, orthopaedic defect

Diagnosis

Condition likely to affect driving

 

No

Yes

Yes

Condition likely to affect driving   No Yes
 

No

Yes

Yes

  No Yes

If No proceed to the next question. If Yes complete the following.

Type

Date of onset

 

Date of last seizure

 

Confirmed by neurologist

24 Hour EEG

No Normal
No
Normal

Yes

Abnormal

Confirmed by neurologist 24 Hour EEG No Normal Yes Abnormal
by neurologist 24 Hour EEG No Normal Yes Abnormal Sleep epilepsy Confirmation by neurologist of "sleep

Sleep epilepsy Confirmation by neurologist of "sleep only" epilepsy during past 12 months

No

YesSleep epilepsy Confirmation by neurologist of "sleep only" epilepsy during past 12 months No

Sleep epilepsy Confirmation by neurologist of "sleep only" epilepsy during past 12 months No Yes

No

YesNo

No Yes

If No proceed to the next question. If Yes complete the following.

Cognitive and/or Intellectual

 

Impairments

 

No

YesImpairments   No

Impairments   No Yes

Dementia

 

No

YesDementia   No

Dementia   No Yes

Traumatic Brain Injury

 

No

YesTraumatic Brain Injury   No

Traumatic Brain Injury   No Yes

Loss of Limb Control

 

No

YesLoss of Limb Control   No

Loss of Limb Control   No Yes

TIA/Syncope/Blackout (specify year)

No

YesTIA/Syncope/Blackout (specify year) No

TIA/Syncope/Blackout (specify year) No Yes

Strokes (specify year)

 

No

YesStrokes (specify year)   No

Strokes (specify year)   No Yes

Neuromuscular Condition:

 

Diagnosis

 
 

No

Yes  No

  No Yes

If No proceed to the next question. If Yes complete the following.

Sleep Apnoea

 

No

YesSleep Apnoea   No

Sleep Apnoea   No Yes

Narcolepsy

 

No

YesNarcolepsy   No

Narcolepsy   No Yes

Well controlled

 

No

YesWell controlled   No

Well controlled   No Yes

eg. psychotic state, depression, schizophrenia.

 

Diagnosis

 

Condition likely to affect driving

 

No

YesCondition likely to affect driving   No

Condition likely to affect driving   No Yes
 

No

Yes  No

  No Yes

If Yes complete the following.

 

Non-prescribed drugs

 

No

YesNon-prescribed drugs   No

Non-prescribed drugs   No Yes

Indication of alcohol abuse

 

No

YesIndication of alcohol abuse   No

Indication of alcohol abuse   No Yes

6. Epilepsy

7. Neurological Condition

8. Sleep Disorder

9. Mental Health/Nervous Disorder

10. Drugs likely to affect driving

Comments on any condition likely to affect driving. Append additional pages if necessary.

Doctor's Certification

The person whose name appears on this application was examined by me today in accordance with the published

guidelines for the class of licence held or applied for and is

considered:

Fit to drive

licence held or applied for and is considered: Fit to drive Unfit to drive IF UNFIT

Unfit to drive

applied for and is considered: Fit to drive Unfit to drive IF UNFIT ONLY: Please indicate

IF UNFIT ONLY: Please indicate if the licence holder is fit to hold an alternative class of licence as shown below. Accordingly, the licence class will then be downgraded.

 

Vehicle Type

 

Current Class

Car  C

 

C

Motorcycle  R

 

R

Light Rigid (eg. light truck, small bus) (eg. light truck, small bus)

 

LR

Medium Rigid (eg. truck bus) (eg. truck bus)

 

MR

Heavy Rigid (eg. heavy truck, heavy bus) (eg. heavy truck, heavy bus)

HR

Please

indicate

if

any

restriction

or

assessment

is

recommended:

Recommended restriction (if appropriate)

 

not more than (tick box) from home

 

2km5km 10km 15km 20km

5km2km 10km 15km 20km

10km2km 5km 15km 20km

15km2km 5km 10km 20km

20km2km 5km 10km 15km

30km40km 50km 75km 100km

40km30km 50km 75km 100km

50km30km 40km 75km 100km

75km30km 40km 50km 100km

100km30km 40km 50km 75km

Daylight hours only 

 

Modified vehicle50km 75km 100km Daylight hours only   RTA Driving Test Occupational therapist driving assessment

RTA Driving Test100km Daylight hours only   Modified vehicle Occupational therapist driving assessment   Referred

Occupational therapist driving assessment 

 

Referred to appropriate specialist (nominate below) (nominate below)

Please indicate review period:-

No further review requiredspecialist (nominate below) Please indicate review period:- Normal RTA review period Other (specify) Doctor's name

Normal RTA review periodPlease indicate review period:- No further review required Other (specify) Doctor's name (please print) Business

Other (specify) (specify)

Doctor's name (please print)

period Other (specify) Doctor's name (please print) Business address Postcode Signature Provider number (if not

Business address

Postcode

Signature

name (please print) Business address Postcode Signature Provider number (if not previously given on page 3)

Provider number (if not previously given on page 3)

Provider number (if not previously given on page 3) Office telephone number Date Day / Month

Office telephone number

(if not previously given on page 3) Office telephone number Date Day / Month / Year

Date

Day

/

Month

/

Year

Mobility Parking Scheme (MPS)

Mobility Parking Scheme (MPS)
Mobility Parking Scheme (MPS)

Conditions of use and Parking concessions

Please detach this page from your completed application form and retain for easy reference.

Displaying your permit

Parking concessions

From September 2010 disability parking permits issued by the RTA consist of two parts: an Australian Disability Parking permit and a Mobility Parking Scheme permit. To validate the Australian Disability Parking permit, the Mobility Parking Scheme permit must be inserted in the plastic sleeve. As a courtesy, the RTA can supply a suction cup to attach the permit to the vehicle window. You are not required to use this device and may use other means or devices that do not obscure the permit details or the driver's vision.

The MPS permit entitles you to park in spaces marked with a symbol for people with disabilities. The permit also provides parking concessions in other spaces:

When parking in metered, coupon or ticket parking areas, no charge is applied.permit also provides parking concessions in other spaces: Where parking is limited by a sign to

Where parking is limited by a sign to more than 30 minutes, the vehicle can park for an unlimited time.coupon or ticket parking areas, no charge is applied. Where parking is limited by a sign

Where parking is limited by a sign to 30 minutes, the vehicle can park for 2 hours.than 30 minutes, the vehicle can park for an unlimited time. If you choose to use

If

you choose to use the suction cup, the manufacturer advises

Where parking is limited by a sign to less than 30 minutes, the vehicle can park for a maximum of 30 minutes. less than 30 minutes, the vehicle can park for a maximum of 30 minutes.

At a 'No Parking' sign you may park up to 5 minutes, the driver must remain within the vehicle or within 3 metres of the vehicle to drop off or pick up passengers or goods.Where parking is limited by a sign to less than 30 minutes, the vehicle can park

that the suction cup's effectiveness is improved when used on a clean windscreen. Use of an alcohol wipe is recommended as some window cleaners may leave a residue.

Conditions of Use

A

MPS permit is issued subject to the following conditions - heavy

All other parking rules apply.A MPS permit is issued subject to the following conditions - heavy

penalties may apply for failing to adhere to these conditions:

a) The permit must only be displayed when the vehicle is being

used to transport the individual to whom the permit was issued. It cannot be used when running errands for or visiting

Note: Commercially owned parking facilities determine their own fees and charges.

 

a

permit holder who is not travelling in the vehicle.

When do the concessions apply?

b) The permit should be displayed unobscured on the left hand (passenger) side of the vehicle on either the vehicle's windscreen, or on any window. If this is not practicable, it should be placed in an area where the whole of the permit may be viewed from outside the vehicle. The sides marked 'THIS SIDE UP' or 'Display this side' must face out. The permit may be attached to the vehicle by any method that does not obscure any of the permit details or the vision of the driver when the vehicle is in motion.

The parking concessions apply when the MPS permit is displayed on the vehicle where it is being used to transport the individual to whom the permit is issued.

Invalid MPS permits

A

MPS permit becomes invalid if it expires, is revoked by the RTA

or

the permit holder is deceased. Display of a MPS permit that is

invalid can result in a heavy fine being issued.

Changes in your Medical Condition

c) The permit must be produced on direction from a police officer or other authorised officer.

d) The permit is valid until the date of expiry, unless it is revoked.

your medical condition improves and you no longer require the use of your MPS permit, you are required to return your MPS permit to your nearest motor registry.

If

e) The permit can no longer be used once it expires. It must be renewed and a current permit displayed for any disability parking concessions.

f) The permit must be returned to a motor registry on expiry, if it is revoked by the RTA or if the permit holder becomes ineligible (e.g. no longer suffers from the disability that made them eligible for the permit).

 

Hotline

Abuse of the MPS can be reported by phoning 1300 884 899 or emailing Customer_Service_Centre@rta.nsw.gov.au

g) The permit must not be reproduced, copied, defaced, altered or destroyed.

h) The permit is not valid if reproduced, copied, defaced or otherwise altered or where one or more of the details on the permit (e.g. permit number or expiry date) are illegible.

i) the permit is used in another State or Territory, it may be used in accordance with prevailing parking concessions.

If

j) The permit may be confiscated by an authorised officer and/or revoked by the RTA for misuse or breach of any of these Conditions of Use.

k) The permit is subject to any other such conditions that may be imposed by the RTA.