Application For Accessible Parking Space Program Driver Only Application
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4REVISED May 1, 2014 – Previous Versions No Longer Valid
CITY OF BOSTON
OFFICIAL OFFICE USE ONLY:
Approved: CRM_______________________
Denied:
Reason_____________________
Appeal:
Approved
Denied
Staff: ______________ Date: _______________
Application for Accessible Parking Space Program
DRIVER ONLY APPLICATION
RETURN COMPLETED APPLICATIONS TO:
Mayor’s Commission for Persons with Disabilities
Boston City Hall, One City Hall Square – Room 967, Boston, MA 02201
Phone: 617-635-3682
Fax: 617-635-2726
TTY: 617-635-2541
Information must be printed clearly, all questions must be answered completely, & supporting documentation must be
included – incomplete applications will be returned, resulting in a delay of processing the application.
Today’s Date: ______________________________
Application Type: NEW
RENEWAL OF EXISTING SPACE
1. APPLICANT INFORMATION (APPLICANT refers to the person with a disability who is in need of parking)
Last Name _________________________________ First Name ________________________________ Middle ___________
Address ___________________________________ Neighborhood _____________________________ Zip _______________
Unit # ______________________ Date of Birth ____________________________________________ Age ______________
Phone _________________________________ Email ___________________________________________________________
In terms of operating the vehicle, is the applicant: The Only Driver The Primary Driver
Only a Passenger
** IMPORTANT – If you do not drive & are always a passenger, STOP here and fill out the PASSENGER APPLICATION **
How often does applicant leave home using this vehicle? Daily Weekly Other (how often? _____________)
If “Daily,” describe where you go on a daily basis: _______________________________________________________
If “Other,” explain frequency you leave home using this vehicle: _____________________________________________
2. VEHICLE INFORMATION (VEHICLE must be registered and located at the applicant’s address)
Vehicle Make _____________________ Model ___________________________ License Plate Number __________________
MA-RMV Disabled Placard Number ____________________________________ Expiration Date _______________________
Applicant’s MA Driver’s License # _____________________________________ Expiration Date _______________________
A copy of each of the following documents is REQUIRED to be submitted with this application – Did you enclose:
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Copy of Vehicle Registration for a car located at the Applicant’s Address
Yes
No
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Copy of Applicant’s Disabled Parking Placard (showing photo & expiration date)
Yes
No
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Copy of Applicant’s Driver’s MA Driver’s License (showing photo & expiration date)
Yes
No
Is this vehicle modified with adaptive equipment (ramp, lift, hand controls, etc?)
Yes
No
If “Yes,” describe modifications: ________________________________________________________________________
__________________________________________________________________________________________________
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