APPUCATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
78027
An application will not be considered complete unless:
• AD lines of the application have been completed in fii)
• A check or money order for $70.00 made payable to t Please note: The application fee shall be waived for a <
• Disability must be permanent as evidenced by a copy submitted at the time of application;
• Proof of residency, in the form of a copy of your driver, time of application.
Completed application forms may be returned to: the office j ^
facility, or via mail at P.O. Box 803100, Chicago, IL 60680-j fee wffl be billed to you annually. Should you have questior < v
744-PARK (7275). V-
/enue enance at 312-
1. Date of Birth
MO _ DAY
2. State Identification Number
3. Drivers License Number
4. Applicant Last Name
Ml 1 Rrst Name
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5. Home Address (primary residence)
SIBEET NUMBER OW. I STREET NAME
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6. Address where signs will be posted
STHEET 8UWBER om. street name
WARO NUMBER
1.3 I 6
'^f. Phone Numbers
Home
Business
8. Current Permanent Disabled Placard Number
Registered to
Loners fie^^H
Relationship to Applicant
9. Current License Ptate Number
Registered to
City Sticker No.
Relationship to Applicant
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10. Description of Medical Condition and Disability
atlon
; Atterrtative Parking: Please note your application may be denied if you have altemative accessible off-street parking options.
11. is there off-street parking available at your primary residence (Le., garage, car port, driveway, etc.)? _
YES
12. «f,y
13. is v
you answered Yes to question 11, please describe: Garage; ? Driveway; ? Car Port; , ? Other
13. Is your off-street parking accessible? -QYes; ? No. Please explain: ^ r/(y^<^(4^^
14, Affirmation: I hereby affirm thai the above information is true and correct. If the City of Chicago Department of Revenue deter/nines thai the (jppflcant ha...
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