Feb 04 2011
773-523-8440
77402
An
10:15PM HP LASERJET FRX
>appucation for disabled parking signs Please read the following carefully -4ep6re completing the form
application will lot be Sons^i^O complete unless: <*"0 I ii , All »ines of the application have been completed in full; •jgw-^- %f "T"| K^<^. ¦ A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please nole: The application fee shall be waived for any person holding a valid, current disabled veterans plate.
• 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;
• Proof of residency, in the lorm of a copy of your drivers license, slate identification, or utility bills are submitted at the time of application.
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department of Revenue 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 312-744-PARK (7275).
i. Date of Birth MO _ DAY YEAR il* ! ol 6 1 n 14 2. State Identification Number ! 1 1 T I i Mill 3. Olivers License Number giai^Thiaid \n~^\3\^\°i
4. Applicant Last Name iQohdmlflUni l 1 l 1 I l l l l Ml i First Name poisiei l I I i 1 M
S. Home Address (primary residence)
STREET NUMBER
3HL517
STREET NAME 11
i zip cooe
Ml Mil I I 11 1 I, I 1 I
6. Address where signs will tie posted of. OoWdWi 3*VG~7 1*3 7»SrtX> SWeeV
•/^TREET NUMBER I OIF. I STREET NAME Z3 «"*W«»»-|
U*'A^ Lclae+A^ ^iu.i etn.rVU.uUi
iui J I l 1M31
7. Phone Numbers ' Home Business
01 O I a I K lo
i_La
8. Current Permanent Disabled Placard Number
3 IS
WARD NUMBER
Registered to
Relationship to Applicant
Registered to...
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