Mar 09 2011 4:17PM
HP LASERJET FRX
773-523-8440
p.2
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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65031
An application will not be considered complete unless:
• All 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 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 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 of Birth
MO _ DAY
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2. State Identification Number
3. Drivers License Number
4. Applicant La3t Name
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First Name
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5. Home Address (primary residence)
STREET NUMBER DIR. I STREET NAME
STREET NUMBER DIR. I STREET NAME , f ^ _
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6. Address where signs will be posted
STREET NUIKR OIR. | STREET NAME . Jl f |
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7. Phone Numbers
Home
111 I3TI0I7-RT^I )
Business
B. Current Permanent Disabled Placard Number
Registered to Roy?.*- Bf^i-V-Vrrrx
Relationship to Applicant D* A_
9. Current License Plate Number
Registered to
City Sticker No.
Relationship to Applicant
10 Description of Medic...
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