Parking Program For People With Disabilities Form
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2Parking Program for People with Disabilities
Send completed application to the Saskatchewan Abilities Council, 2310 Louise Avenue, Saskatoon, SK, S7J 2C7,
or your nearest branch. Faxed or photocopied applications will not be accepted.
SECTION 1
APPLICANT INFORMATION (Applicant is the individual with the mobility impairment.)
Check one of the following:
Applying for the first time.
Applying for the renewal of existing short term or long term permit.
Applying for the renewal of existing permanent permit. I self-declare that my medical condition has not changed and
I still require a parking permit.
Applying for the replacement of a:
i) lost _____
ii) stolen _____
or iii) damaged permit _____.
(Damaged permit must be returned before replacement will be issued.)
PLEASE PRINT CLEARLY - Incomplete/illegible applications will be returned.
Surname: _________________________________ First Name: _____________________________ Middle Initial: _______
Address:____________________________________________________________________________________________
Street Number & Name, Box Number
City/Town
Postal Code
Date of Birth:___________________
Daytime Phone Number: _______________________________
Day
Month
Year
I, the applicant, acknowledge that:
I am applying for a parking permit and the information provided on this application is true and correct.
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The parking permit will only be used when the applicant is present. Any misuse of a parking permit will result in the
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permit being cancelled and the refusal to issue a parking permit in the future.
I am responsible for any costs related to completing this application.
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If applying for a replacement of a lost or stolen permit, I declare the permit is unavailable for return.
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For audit purposes the information may be shared with SGI.
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I am responsible for advising the Saskatchewan Abilities Council of any address changes.
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Signature of Applicant or Parent/Guardian
Date
NOTE:
All information must be completed for processing. When the application is completed by the healthcare professional, it must be submitted
to the Saskatchewan Abilities Council within 3 months or a new application will be required.
METHOD OF PAYMENT -
Permit Fee: $10.00.
Permit Fee is non refundable.
Cheque or money order payable to the Saskatchewan Abilities Council.
Please do not send cash in the mail.
All NSF cheques will be subject to an additional $15.00 administration fee.
Cheque
Money Order
Interac
Cash
Visa
Name on Card: _____________________________________________________________
MasterCard
Card Number: ______________________________________________________ Expiry Date: __________/__________
SASKATCHEWAN ABILITIES COUNCIL OFFICE USE ONLY
Permit Type:
Expiry Date:
Permit Number:
(ST, LT, P)
Approved
Not Approved
Authorized by:
Date:
Branch:
1337-15
Page 1 of 2
06/2012
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