APPLICATION FOR D ISABLED F AF KING SIGNS PLEASE READ THE f=OLLOWING CAREFULLY BEFORE COMP LETING THE FORM
7361.
An application will not be considered complete unless;
All lines of the application have been completed >n ful,
A check or money order for $70.00 made payabh? to I .e City of Chicago s submitted as payment of the application fee-Please note. The application fee shall be waived foraiy person hoidng < valid, current disabled veterans plate.
Disability must be permanent as evidenced by a :opy of your valid di ^ab, »d placard and/or currant vehicle registration submitted at the time of application;
Proof of residency, in the form of a copy of your cnve; license, state idei tificat on. or utility bills are submitted at the time of application.
Completed application forms may be returned to: the off id- of your alderman, iny City of Chicago Department of Revenue ■ facility, Or via mail at P.O. Box 803100. Chicago. IL 6O580- 1100, ATTN: Di.;abl >d Pemitting Section. A $25.00 maintenance fee will be billed to you annually. Should you have qusstio is or concerns, pie isecall our permil processing division at 312-744-PARK (7275).
1. Date of Birth
MO __DAY
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YEAH
4. Applicant Last Name
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2 Stare Identification Nui nb«r
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5. Home Address (primary residence)
. , STREET NUMBER DIR. I SWEET NAME I /-> /
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I. I irivers License Number
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Fir ;t Name
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6. Address where signs will be posted
STREET NUMBER | OIR I STREET NAME
ZIP CODE ^
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STREET NUMBER I OIR I STREET NAME
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7. Phone Numbers Home
WARD NUMBER
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8. Current Permanent Disabled Placard Numbe
9. Current License Plate Number
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Business
Registered t<
Ragisti red to
City Stic ;er No
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Relationship to Applicant
Relationship to Applicant
10. Description of MeJical Condition and Disability
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Alternative Parking: Please note your apptfcation may be denied if y>u have alternate e at ;essibe off-street parking options,
11. Is there off-straet parking available at your primary residencs □ YES ^ NO
(i.e garage, car port, driveway, etc.)? __. ■ .■__
12 If you answered Yes to question 11, please describe: □ Garage; □ Driveway; □CerPort: □ Other:
13.1s your off-streel parking accessible? □ Yes; Q No, Please explain:
14. Affirmation; I hereby affirm that the above information is trun-ancl correct If the C ty o Chicago Department of Revenue determines lhal the applicanl has falsely represented one or more of the above conditions, the apjlica ii shall be subject to a fine of nol less than $100 but no more than $500, and the application shall be denied. I alio understand thil it s my responsibility to notify the Department ot Revenue of any changes in the information provided.
Signature,,
Date
FOR OFFICE USE^O^LY
□ PI AnAFtn/Pl YTF
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