Jan"»14 2011 1:24PM
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AppucaaTON mm omsim parking signs
PLEASEREAD THE POUJQWIW C^EFUUY BffORECOMPt^rTOTHEFOfW
77298
An appfeeSon win not be considered complete unless:
• AS ftw$ ot 9s application have been completed in full;
• A Check or money order for $70.00 made payable to the City ol Chicago is submitted as payment of the app^p&tjon fee; Pteese rate: The atppilcatjan tee shafl be waived for ot^
• DtsaMtty rm»t be permanent as evidenced by a copy ot your valid disabled placard and/or current vatTtc* regpttreGdn. eubmSed at the fime of appKcatton;
• Pmcf of njriooncy, in tite form oi a copy ot your drivers ttoense, state identtfkation, or utttty bats are ©Ararfte* at the time of appfcation.
Completed appfeaSofl forms may be returned to: the ofdoe of your atderman, any City of Chicago Department of Revenue fecffity, or vfa nal at P.O. Bom 803100, Chicago, fL 60680.3100. ATTN: Disabled Perrnttring Section. A S2S.O0 matnteratnoe fee wtt-be bled to you annually. Should you nave questions or concerns, please call our permit processing division at 312-(727S).
1. Date of Kith MD _ OM - «*B- c\% \ / i e i vi? 2. State Identification Number 1 1 1 T 1 1 Ml 1 1 i 3. Drivers License Number
4 ApptatttAetNane Ao\*>\*)\£\\\ I I l I l I l l l l Ml Pint Name /T^fiAei/^i/i/?} iM
6. Adriief* where efgrtewBf be posted .MSinoMuMBan 1^1^ 1 I 1 1 1 1 1 1
r. H^Nurobere Home 8usiness JUoK)£ ! 1 1 1 1 1 1 i !
$. Current Peitnanent Disabled Placard Number Registered to ffteiarlonship lo Appfcant
9. Currant License Plate Number Ctty Sticker No. Ratattomhip to AppftcBnt
10. Description ol Medical Condition and DtoabBlty _
Alternative Psrlcng: Please note your application may be denied tf you have altemative accessible off-street panting options.
11 Is there off-streot pa/king available at your primary rsatctenca ? YES QftlO (i.e garage, car port, driveway...
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