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Get Disability Placard Form

Person) NO FEE REQUIRED FOR DEPARTMENT USE ONLY ) APPROPRIATE BLOCKS BELOW - See reverse side for instructions and eligibility requirements Harrisburg, PA 17106-8268 CHECK ( ORIGINAL REQUEST - Permanent Placard Severely Disabled Veteran Temporary Placard RENEWAL REQUEST - (For Permanent Placards Only) REPLACEMENT REQUEST - PLACARD ID CARD Defaced Lost Stolen PREVIOUS PLACARD # CHANGE OF ADDRESS/NAME A APPLICANT INFORMATION - LIST NAME AND ADDRESS OF PERSON WITH DI.

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