Form 2769 (Revised 08-2024), Application for Disabled Person Placard Completed Form Examples and Samples
View completed examples and samples of Form 2769 (Revised 08-2024), Application for Disabled Person Placard. Learn how to correctly fill out each section for temporary, permanent, or travel placards to ensure your application is accurate and processed without delay.
Form 2769 Example – Temporary Disabled Person Placard
How this form was filled:
This is an example of a completed Form 2769 for an individual applying for a temporary disabled person placard. The applicant's information is fully provided in Section 1, and a licensed medical professional has completed and signed the required certification in Section 2, indicating the nature and expected duration of the temporary disability.
Information used to fill out the document:
- Applicant's Full Name: Jane Marie Smith
- Date of Birth: 06/15/1985
- Driver License or ID Number: D5432109
- Residence Address: 456 Oak Avenue, Anytown, CA, 91234
- Mailing Address: 456 Oak Avenue, Anytown, CA, 91234
- Phone Number: (555) 123-4567
- Placard Type Requested: Temporary
- Certifying Medical Professional: Dr. Alan Grant, MD
- Medical License Number: A98765
- Medical Professional's Phone: (555) 987-6543
- Disability Description: Limited mobility due to a complex fracture of the right tibia. Cannot walk more than 50 feet without assistance.
- Expected Recovery Date: 09/30/2026
- Applicant Signature Date: 03/10/2026
- Medical Signature Date: 03/09/2026
What this filled form sample shows:
- Clearly completed Applicant Information in Section 1.
- Correct selection of Temporary Placard type.
- Detailed and compliant Medical Certification in Section 2 by a licensed professional.
- Properly signed and dated by both the applicant and the medical professional.
- Includes a specific expected duration of disability, as required for a temporary placard.
Form specifications and details:
| Form Name: | Form 2769, Application for Disabled Person Placard |
| Revision Date: | 08-2024 |
| Jurisdiction: | California Department of Motor Vehicles (DMV) |
| Use Case: | Individual applying for a temporary placard due to a recent injury requiring medical certification. |
Created: January 29, 2026 07:10 AM
