APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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'.An acplicaticn wiil not be considered complete unless:-' > ':' M lines ol tne application have baen completed in full; - : ■■ , ,' -;
A check o" money order fp'$70.00 made payable to tne City of Chicago is submitted as'payhient cif-lh'e'applicaikjn tee: P>ease note: The application fee snail be waived lor- any peison holding a val.di'current disable* v^ic-'a.-i's plat*,. , inability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration biiomiiteu at the time.-a', application; ... Proof ol residency, in the form of a copy of your drivers license, state identification, or utility bills 'aie; submitted at the time of application.
C-opipMrtcU app'.cation fouris may be returned to: the office of your aldennan. any City of Chicago Dep.ir:':i ' h;./!;.w- ■ & , (ncilitv or via mat! at P.O. Box-803100. Chicago; IL 60680-3100. ATTN: Disabled Permitting Section; .A $25.00 maintenance: ■ ee will be billed to you annually. Should you have questions or concerns, please cad nurperrhil pmccssinq.vi 'k- 3">2~ 74-1-PARK (7275). " ' .'v ' : '.'-. <
O.iU; oi Birth
2. State Identification Number
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; Homo Ac:d!CSS.Iprini;iry residence)
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3. Drivers License. Number
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Firs! Name ■: ■ ■: :" ; ; ,". J"\
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A'.:-.: when, sign:- will t>.: pcsv-j-J
i 7. Pttsne fturnhcrs
Homo
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Business
Cut rent >o;:rv.nen! Oisat/.-d Ph.;arr.l Numhr
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3. C'iien; Licon".-:: Piato Numoer
Re-nisioroa to
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?0. D«:;cnptmn ol Mediryi Condition nnd Disability
iii-.'i: r.ir'-,' Plt.-.ise noiD yo'-.'f ;«:p!ica:iort may lie denied ii you have alternative,nccessifcte oW-strocrpaiking <n;!<«rts'.
l;; the-** ort-strac? oar king nvallBWo at vour primary resicynco-si.e. ci.i ;Oi . :,a,' poi;. cliivow&y. etc.tV
2.YES J NO
;;?.irvou answu.i Y-;;., (o question n, please describe:
. >£l Garage; J Onvuway: J C:» Pott, 'J Other;'
!■, v":in r'f-sru-P! p:irkinc: ao■co,::^■i^k?,
J Yes: yd Ho. PIchso explain, ik? . -j, . k t-. 7- , - t,. -u /= 'i
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. !4. Arlirniaiion: i nereby aliirm thai the above inlormaiion'isi true and corroci. I< llio City ot Oacago Diparimenl or ns- :f.t,:c t:i.:-...-: ,n ;■:>! '- ie apt:-Ta- ,»ic3 f- 'isciy represented one or mere of |h« above condilions, ihe applicant s^ait he subject to-a tins &. hot-lr--ss t'-.^n" S'100 bat no more than $500, and tiio application shaH be cinniad. I also understand thai it is my responsibi rv to :nc Oci^r'Tid ■; Ffi'v-\'U:0 of any ''iiaii;.;os in tho intoimat-oa provicied.
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PGR' OFFICE, USE'ONLV^-il FEE
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kJ'PLACARD-PLATE ' J RESIDENCY
□■:COMPi_bTE