APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
76943
An application will not be considered complete unless: Ail line:; of ihe application have bean completed in lull;
A rivKk ■>- money oider 'or S70.C0 made pay.ible.to ihe City ol Chicaoo is submitted as payment of |i\* vicolicafion fee. ^Please noitv The applicaiion fee shall be waived for any person holding a valid, current disabled veterans alak .-
? _ i.k.^b.hiy viiist i:e permanent Hf> evidenced oy a copy of you: valid d:-s.ibktd placard and/or current vphicte rfrgistr/jt on
suomitfed al the tine of application: -* Piool ol tesidency. in the form ol a copy oi your drivers license, state 'deniihea: on. oi utiltiy biifs^ire fcubrr'nei at. ■nv' of a-.jphcaran.
)ni;';e;6u application terms rnav be relumed to: the ofl-ce of your alderman, any City of Chicago Department nf "-Ayenup facility or via mail at P.O. Box 803100. Chicago, IL 60680-3100. ATTN: Disabled Permitting Section.'A $25.00 -n;;internet; fee will be billea lo you annually. Should you have questions or concerns, please cail out pfirnii p;o~;.u;;'>ing d-. ■■ :■■ ;:: > 3'12-?-W-PARK-t7275).
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?. State? lcren;ific,-i»ion Number
3 Driven; License Number
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AppNcHni Last Name;
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Ml jl First Narnjp
| S. Horns Adores:- (primary resfence:
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Acid &is when.' ■jy-w writ bo postal
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C:;i"-:ni !'i>tr.:; Disabled Placard Ni;mbi:>.-
Current License PL,to Number
Registered to
I Relationship Appiicar
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Registered to City Slicker No
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Roietionsriip Apphcani
ti Dii:«.['ip;,on q- Medical Condition t;na Disability
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wrmwi ;,.itj.i: (j- Ptsassp note you' apr'icatinn may be denied if you have alternative accessible off-street p?>-k;ng cations.
is :i■!■!■(. .'ti-siiroi pisrkif!<j ay.iilablo at your piirnaiy residence *ij Yt-.S 'i/r-iO
(i.ii. cjiitaye, cur pen, driveway, etc.)? '
P ■,■ .ii aiw,vi«tU V^s ro '.:i.it-.,tiun it. t.;'ist: Jescilbi^
G-'ira<i«: □ Dnveway: □ &»' Port. □ Other; . Is your otl-strcct pa.-Kin-j atwessibio? J V-'s; Ql-io. r,:,sc ■
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l.;. A:;inn.::i:an; 1 hereby aliirrn t'ria.i^nti afcovti iniornatio'i is true and correct. K IK: Civ ol Chicago Ocpart-ocra Rf.vo:-! ''that the- nnpi'iroit! has falsely rcpf.oscnted one or mere of the above conditions. Hie applicant shall be subject to a fine of not iJ'OO ::ut m inon/ .than $500, and the api>i;c«i>on sttall be dcn:ed. I also unaerstand ib^t it'is my M,>spin$ibi<ny tc notifyJ.-^- D :;^;vO!ii'; i'-f :;mv chnn'ir-s i'1 iho infonnati^ri provided -
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SL?jna!ura
Date
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FOR OFFICE USE OWLY
■.y'FEE
-a PLACARD/PLATE -J RESIDENCY J COMPLETE