Application For Accessible Parking Space Program Driver Only Application Page 2
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4REVISED May 1, 2014 – Previous Versions No Longer Valid
3. PROPERTY INFORMATION
Do you own the property where you are requesting the Accessible Space to be installed?
Yes
No
Is there ANY off-street parking at this address, such as a driveway, parking lot, or garage?
Yes
No
* * * IMPORTANT – You must report ALL existing off-street parking at this address even if you cannot use it * * *
If you answered “Yes,” are you able and/or allowed to use the off-street parking?
Yes
No
If you CANNOT use the off-street parking, explain why: ______________________________________________________
Is this Public Housing? Yes No If “Yes,” Name of Development: __________________________________________
Do you reside at this address year-round, without extended periods away?
Yes
No
Are there any existing Accessible Parking signs posted in front of your residence?
Yes
No
How many Accessible Parking Spaces are located on your block?
0 1
2
3
Other ________
Check off all parking restrictions at this address: No Parking
Hydrant
Bus Stop
One-way Street
What floor of this property do you live on?
Basement
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2
3
4
Other ____________
#
How do you get into your house / unit?
Ramp
Elevator or Lift
Stairs (
of stairs________________)
4. DISABILITY INFORMATION
What is the medical DIAGNOSIS causing your disability? ______________________________________________________
What SYMPTOMS affect your ability to walk? _________________________________________________________________
How long is your disability expected to last?
Permanently
Temporarily (how long?___________________)
How many city blocks can you walk without stopping to rest?
_______________________________________________
Are you dependent on any mobility devices that your doctor wrote a PRESCRIPTION for?
Yes No
If you answered “Yes,” which devices? wheelchair
portable oxygen prosthesis walker
cane
If you answered “Yes,” did you enclose the REQUIRED copy of this prescription?
Yes
No
Are you employed?
Yes No
If you answered “Yes,” are you employed full-time or part-time?
Full-time
Part-time
If you answered “Yes,” what is your occupation? ____________________________________________________________
5. AUTHORIZATION BY APPLICANT
I certify that the above information is true and accurate. I fully understand that the installation of Accessible Parking signs at my
residence does not reserve a parking space for my personal use. It makes a space available for use by any vehicle with a valid
Disabled plate or placard. I understand that abuse or violation of this agreement may result in removal of the Accessible Parking.
____________________________________________________________
_______________________________
Applicant Signature
Date
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