^ 02-04-11;12:43PM;
7734343889
APPLICATION FOR DISABLED PARKING SIGNS READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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77509
An application will not be considered complete unless: ¦ All lines ot 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 tee: Please note: 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;
• Proofof residency, In the form' of a copy of your drivers license, state identification, or utility bills are submitted ai the time of application.
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department o' Revenue facility, or via mall at P.O. Box 803100, Chicago. IL 60660-3100. ATTN: Disabled Permitting Section. A £25.00 maintenance fee wflt be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (727S).
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1. Date of Birth
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2. State Identification Number
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4. AppllcantLut Name
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3. Drivers Liconse Numbar
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First Name
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S. Home Address (pttmary residence)
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7.1 Phone Numbers
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8. Current Permanent Disabled Placard Number
9. Current License Plate Number
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Relationship to Applicant
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lb:Desct1ptjon of Medical Condition and Disability . ^ / MtemelNie Parking: Please note your applica...
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