APPLICANT INFORMATION (please print or type):
NAME: (Last, First, Middle I.) _________________________________________________________________
ADDRESS: (Street, City, State, Zip)_____________________________________________________________
___________________________________________________________________________________________
DATE OF BIRTH: ____________________________ SEX: (check one) ___ Male ___ Female
I AM APPLYING FOR: (check one) ___ Permanent Permit ___ Temporary Permit
SOCIAL SECURITY NUMBER: _____________________________________________________
TYPE OF DISABILITY: ____________________________________________________________
HOME PHONE: _____________________ WORK PHONE: _______________________________
If you are applying for a minor child, or as a guardian for another person, please provide your name, address and phone number below: ___________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Be certain to include a current Doctor's note with your name and address specifying the type of disability and whether it is a permanent or temporary disability and include proof of residency. We need all three items completed to process this application.
By signature below I understand that this permit is issued to the individual who has the handicap and none other, any person issued special plates or permits, who abuses any privilege, benefit, precedence or consideration arising from the issuance of the plates or permit, may have them revoked.
Signature of Applicant/Guardian (Indicate Relationship if Guardian)
________________________________________________________ Date: ____________________
Return this form with the documents requested to:
Handicapped Permits
Office of the Village Clerk
243 Main Street
Johnson City, NY 13790