J90-002 12/27/05
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: VII lines of the application have been completed in full; (A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans plate. \J /Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration ^ /submitted at the time of application; \J Proof of residency, in the form of a copy of your drivers license, state identification, or utility bills are submitted at the =¥ time of application. *a>-Q. ^/^-^OJT- f^7^
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department of Revenye facility, or via mail at P.O. Box 803100, Chicago, IL 60680-3100, ATTN: Disabled Permitting Section. A $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312- 9 744-PARK (7275).
1. Date of Birth
MO _ DAY
2. State Identification Number
MW _ uni i i t^n _ _ / ¦¦ *
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X. Applicant Last Name Ml First Name
4. Applicant Last Name
IN [X \fl
3. Drivers License Number
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5. Home Address (primary residence)
STREET NUMBER DIR. STREET NAME
3 1SH/17I W\f\iWh\ \f\L\n \c \e
II ZIP CODE
6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
l7 I \m.r\L \P\L\fi\c \g
(l \H \L
'ARD NUMBER
Mil
7. Phone Numbers
Home
Business
7 p [3 | 7 \3 \S Qi\l
9 \7
3 I / |A I 51 o IS" I ^\S 17 13
8. Current Permanent Disabled Placard Number
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