APPLICATI3N FOR DIS/ BLED PARKING SIGNS PLEASE HEAD THE FOLLOWING CAREFULLY BEFOR E COMPLE TING THE FORM
73604
An application will not be considered corr )lett: unless:
• An lines of the application nave been :orr. oleted in full;
• A check or money order for $70.00 m ide oayable to the Oity of Chicago is submitted as payment of the. application fee,
shai be vaived for any persen holding a valid, current disabled veterans plate, evid in«d by a copy of ''O'Ji'valid disabled placard and/or current vehicle registration tion;
Proof of residency, in the form, of a cc iy clyour drivers; lii.enst;, state identification, or utility bills are submitted.at the time of application.
Please note: The application iat Disability must be permanent a; submitted at the time of applica
Completed application forms may bo retu ned to: the office of youi alderman, any City of Chicago Department of Revenue facility, or via mail at P.O. Box 90311)0, CI icaf.0, IL 60680-31CO, ATTN: Disabled Permitting Section. A $25,00 maintenance, fee will be billed to you annually, Should 'ou lave questions or cc'ncsrris, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO _ DAY
/ I O \ I I V II 9-
V Sta ? Idnntificaiion Numb'r
4. Applicant Last Name
H\0 \b\t W\f\oM
J.
3. Drivers License Number
J_J_L
Ml First Name
J\B\o \n\a/\i \e
S. Home Address (primary residence)
STREET NUMBER I OIK. I STREET NAME l
U I n i s j lu./l 0 I A IT l o l, A l o J n I \A....,/l.-=M
ZIP CODE
\L\A\/, i -C i / .
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6. Address where signs will be posted
, STREET NUWBCR
H\0\3 \?DIR
STREET NAMfc'
7. Phone Numbers
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Home
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Business
8. Current Permanent Disabled Placard Mumb r
9. Current License Plate Number|1010|J____L
Registered to
_ Register id to
ft-ev\-e.e- o
City SticKer No.
If 36> 797-
Relationship to Applicant
Relationship to Applicant per e'e. (I. Ik}/ f11 a
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iu. Description of Medical Condition and...
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