2012 Illinois Rules of The Road Review Course Workbook
Transcript of 2012 Illinois Rules of The Road Review Course Workbook
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The Secretary of States Emergency Contact
Database allows Illinois drivers license and
ID cardholders to enter emergency, disability
and special needs contact information into a
voluntary, secure database. In the event of amotor vehicle crash or other emergency situ-
ation when a person is unable to communi-
cate directly, law enforcement can access the
database to help reach the persons desig-
nated contacts.
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JESSE WHITE SIDE A
Secretary of State State of Illinois (To be completed by physician)
Persons with Disabilities Certification for Parking PlacardDIRECTIONS: Both sides of this document must be signed and completed. Side A must be completed by the physician andSide B must be completed by the applicant.
DEFINITION: PERSONS WITH DISABILITIES (625 ILCS 5/1-159.1)
A natural person who, as determined by a licensed physician: (1) cannot walk without the use of, or assistance from, a
brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device; (2) is restricted by lung dis-ease to such an extent that his or her forced (respiratory) expiratory volume for one second, when measured by spirome-try, is less than one liter, or the arterial oxygen tension is less than 60 mm/hg on room air at rest; (3) uses portable oxygen;(4) has a cardiac condition to the extent that the persons functional limitations are classified in severity as Class III or ClassIV, according to the standards set by the American Heart Association; or (5) is severely limited in the persons ability to walkdue to an arthritic, neurological, or orthopedic condition; or (6) cannot walk 200 feet without stopping to rest because of oneof the above 5 conditions; or (7) is missing a hand or arm or has permanently lost the use of a hand or arm.
Please fill in the name of the person with the disability, state the diagnosis, and indicate the impairments below.
Name of Person with Disabilities: ____________________________________________________________________
Diagnosis:________________________________________________________________________________________
NOTE: Cannot walk 200 feet without stopping to rest is no longer a qualifying disability unless it is related to one of thefollowing conditions below.
____ Is restricted by lung disease to such a degree that the persons forced (respiratory) expiratory volume (FEV) in onesecond, when measured by spirometry, is less than one liter.
____ Uses portable oxygen.
____ Has a Class III or Class IV cardiac condition according to the standards set by the American Heart Association.
____ Cannot walk without the assistance of another person, prosthetic device, wheelchair or other assistive device.
____ Is severely limited in the persons ability to walk due to an arthritic, neurological or orthopedic condition.
____ Has permanently lost the use of or is missing a hand or arm.
LENGTH OF DISABILITY: (Check one) Disability is permanent Disability is temporary; must state duration (maximum 6 months) _________________
I hereby certify that the physical condition of the person with disabilities listed herewith constitutes him/her as a person withdisabilities as described under 625 ILCS 5/1-159.1. WARNING: Any person who knowingly misuses or makes a false ormisleading statement on an application may be fined up to $1,000. PHYSICIANS: Do not sign this form if the patientdoes not meet the above definition. (NOTE: If certification form is signed by a licensed physician assistant or advancepractice nurse, the name and license number of the supervising physician is required.)
_______________________________________________ _______________________________________________Physicians Signature Date Physicians License Number
_______________________________________________ _______________________________________________Supervising Physician's Name Date Supervising Physicians License Number
PLEASE PRINT OR TYPE BELOW:
Physicians Name __________________________________________________________________________________
Address __________________________________________________________________________________________
City________________________________________________State__________________ZIP_____________________
Telephone ( ) _______________________________________________________________________________
Please mail all required documentation to: Secretary of State, Persons with Disabilities License Plates/PlacardUnit, 501 S. Second St., Rm. 541, Springfield, IL 62756, www.cyberdriveillinois.com.
Printed on recycled paper. Printed by authority of the State of Illinois. March 2010 100M VSD 62.20
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JESSE WHITE SIDE BSecretary of State State of Illinois (To be completed by applicant)
DIRECTIONS: Both sides of this document must be signed and completed in its entirety in order for the application to beprocessed. Complete Part 1 if the person with disabilities is applying for disability plates and/or a parking placard. CompleteParts 1 and 2 if the parent, immediate family member or legal guardian of the person with disabilities is applying for disabil-ity plates.
PART 1. PERSON WITH DISABILITIES:
I hereby apply for:
____ Person with Disabilities License Plates (Application and fee for registration must accompany this form. Fee isbased upon the current plate expiration, date of purchase of vehicle if newly acquired, or the date of applica-tion, whichever is applicable.) APPLICANTS MUST HAVE A PERMANENT DISABILITY TO OBTAIN DISABIL-ITY PLATES.
____ Persons with Disabilities Parking Placard
under the statutory provision (625 ILCS 5/1-159.1), and certify that my physical condition entitles me to the issuancethereof. I also am aware that the person with disabilities parking device (plates or parking placard) must not be usedunless I am the driver or passenger in the vehicle.
__________________ ____________________________________________Date Applicants Signature
WARNING: MISUSE OF OR FALSE APPLICATION FOR PERSONS WITH DISABILITIES PLATES OR PARKING PLACARDS mayresult in revocation of the plates or placard, a 30-day drivers license suspension, and a fine of up to $1,000. The authorizedholder of the disability plates or parking placard must be present and must enter or exit the vehicle at the time parking privi-
leges are being used.
PLEASE PRINT OR TYPE BELOW:
Name of Person with Disability __________ OR __________ Date of Birth (Month/Day/Year)
Male Female
Address City ZIP
Drivers License or State ID Card Number of Person with Disability Telephone Number
PART 2. DISABILITY LICENSE PLATES FOR PARENT, IMMEDIATE FAMILY MEMBER OR LEGAL GUARDIAN ONLY:
I hereby apply for disability license plates as the parent, legal guardian or other family member of the individual witha disability. The above named person with disabilities owns no vehicles and relies frequently on me for his/her modeof transportation.
Parents, Legal Guardians OR Family Members Name Date
Address City ZIP
Telephone Number Relationship to Person with Disability( )
............................................................................FOR OFFICE USE ONLY............................................................................
Parking Placard Number ______________________________________ Expiration Date _________________________
Issued By __________________________________________________ Issue Date_____________________________
Printed on recycled paper. Printed by authority of the State of Illinois. March 2010 100M VSD 62.20
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D$IE$ E$ICE FACILI&IE A!D H"'$
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Thank ou for participating in the Secretar of State Rules of the Road Review Course. Theoffice strives to expedite seniors, persons with disabilities and expectant mothers while vis-iting a Driver Services facilit. Depending on the facilit, this ma be an automated or man-ual process. If ou need additional assistance, please do not hesitate to contact a DriverServices emploee at the facilit ou are visiting.
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are YOU registered to be an
organ/tissue donor?
YOUt s up toits up tot s up to
www.LifeGoesOn.com
Join the registry:
Visit www.LifeGoesOn.comComplete and mail a registration card
Call 800-210-2106
Visit any Driver Services facility
Jesse White Secretary of State
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F!# if!#ma%i! !
R&le$ !f %he R!adRe'ie C!$e$
ad !%he# "#!g#am$
!ffe#ed b*
%he Sec#e%a#* !f S%a%e:
D#i'e# Se#'ice$ De"a#%me%
312-814-3676
888-261-5238 (Ne Talk)