FROM ALDERMAN ED SMITH
(WED)JAN 26 2011 11:48/ST. 11:20/No. 6835156618 P 14
»1 «.|10 10|APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
78097
An application will no) De considered complete unless All lines ol the application have been completed in lull:
• A check or money order lor 570.00 made payable to the City ol Chicago is submitted as payment ol me application Ik>>. Please note: The application lee snail be waived lor any person holding a valid current disabled veterans plate
• Disability must be permanent as evideiKed by a copy ol your valid disabled placard and/oi current vehicle rcg'sKit'on submitted at the time of application:
• Proof ol residency, in the lorm ot a copy ol your drivers license, state identification, or utility bills are submitted ,i; tiio time ot application
Completed application forms may be returned to: the office ol your alderman, any Oiy of Chicago Department ot Revenue faciiily, or via mail at P.O. Box 803100 Chicago. IL 60680-3100, ATTN: Disabled Permitting Section. A $25 00 m.nnton.wr tee will be billed lo you annually. Should you have questions or concerns, please call our permit processing divisic- i: :3° r 744-PARK (7275) '
; 1. Oaie of Birth
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7. Slate Idrintilicatiun Numboi
3. Drivers License Number
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i 4. Applicant Last Namo
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Fust N»mL U J S.
5. Home AOOress (primary ros'Ooncet
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6 AdO'ess where signs will tm pusicu
7. Phone Numbers Home ! 8 Current Permanent Disabled Placard Numbor
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j 0 Current LiCOOSO PlilM Numho'
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10 Description ol Medical Conation and Disability
Alternative Partung; Ploaso note your application may bn denied if you have alternative accotsit'lo o...
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