Jan 28 2011 5:57PM
HP LASERJET FRX
7733950146
page 2
77274
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY
BEFORE COMPLETING THE FORM ry\J ^0 Qjfr
An application will not be considered complete unless: tftA ^iJigJ? i— '
• All lines of the application have been completed in full; \J\1\CMS}-*
• A check or money order for S70.00 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.
• 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 form of a copy of your drivers license, state 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-PAFK (7275).
t. Date of Birth
MO _ UAY
VEAH
on io i2> 11 \h
2. State Identification Number
z\i\o\m\on inTnimv
3. Drivers License Number
VI£121012 1* 10 I7lw 1 71« 1^
4. Applicant Last Name
Viaisiqiftie.i?,
Irh
Ml
First Name
mrii'isieidhai
5. Home Address (primary residence)
STREET NUMBER DW. STREET NAME
31315 131 mifclvlfcirlQirlftieifl
fi Adrirojta where skins will bs nnsled
ZIP CODE
I I I I lfcl0lfcl.fl/
6. Address where signs will be posted
STREET NUMBER Om. STREET NAME
:*>I3I5I3 1 Mlflulfelcklrlftlftlrt
7. Phone Numbers unm*
J_L
WARD NUMBER
Home
Business
I i2.
8. Current Permanent Disabled Placard Number Registered to Relationship to Applicant
9. Current License Plate Number QJi
Click here for full text