Mar 08 2011 4:19PM HP LASERJET FAX 773-523-8440
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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An application will not be considered complete unless:
• AM lines of the application have been completed in full;
• A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee Please note: The application tee 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 Ihe 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-PARK (7275).
1. Date ol Birth
MO _ DAY _ YEAH
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2. State Identification Number
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3. Drivers License Number
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4. Applicant Last Name
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First Name
5. Home Address (primary residence)
STREET MUMBER
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IMBER 0B. j STREET MAME II 7/P CODE
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Address where signs will be posted
STREET NUMBER I DIR. STREET NAME
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WARD NUMBER
7. Phone Numbers
Home
Business
8. Current Permanent Oisabled Placard Number Registered to Relationship to Applicant
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9. Current License Plate Number 5~7
10 Description of Medical Condition and Disability Wfl S ', a cow Ace
Alternative Parking: P...
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