Mar
2011 9:53PM
HP LASERJET FAX
773-523-8440
APPUCATION FOR DISABLED PARKING SIGNS 75225 PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: Jk
• All lines ot the application have been completed in full; IQJ W• A check or money order for $70.p0 made payable to the City of Chicago is submitted as payment of the application fee; Please note: The application fee 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 the form of a copy of your drivers license, state identification, or utility bills are submilted 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 of Birth mo _ nur
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 NUMBER j P1W I STREET NAME l
MlUiq-13 1 ISlEln ic lid cull ll 1 ZIP toot
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6. Address where signs will be posted
STREET NUMBER I DIR. I STREET NAME .
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I I I 1112
WAPD NUMBER
7. Phone Numbers
Home
Business
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6. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate Number
Registered to
City Sticker No.
Relationship to Applicant
10. Description of Medical Condition and Disability. „
Alternative Parking: Please note your application may be denied if you have alternative acce...
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