"Handicap Parking Application"
RESIDENTIAL HANDICAPPED PARKING APPLICATION INSTRUCTIONS: 1. COMPLETE THE ATTACHED APPLICATION. 2. ATTACH COPIES OF THE DOCUMENTS LISTED IN THE ATTACHED APPLICATION. 3. ATTACH FIFTEEN DOLLARS ($15.00) CHECK OR MONEY ORDER PAYABLE TO THE “CITY OF NEWARK”. 4. APPLICATION MUST BE RENEWED YEARLY. 5. MAIL TO: CITY OF NEWARK DEPARTMENT OF ENGINEERING DIVISION OF TRAFFIC AND SIGNALS 255 CENTRAL AVENUE NEWARK, NJ 07103 6. APPLICATIONS THAT ARE NOT COMPLETED PROPERLY WILL BE RETURNED. 7. APLICANTS MUST PROVIDE THIS OFFICE WITH ALL NECESSARY COPIES, WE WILL NOT MAKE COPIES OF YOUR DOCUMENTS, NO EXCEPTIONS. 8. APPLICANTS WITH ACCESS TO A DRIVEWAY, GARAGE, AND/OR OTHER OFFSTREET PARKING ARE NOT ENTITLED TO A HANDICAP PARKING SPACE, NO EXCEPTIONS. CITY OF NEWARK DEPARTMENT OF ENGINEERING DIVISION OF TRAFFIC AND SIGNALS RESIDENTIAL HANDICAPPED PARKING APPLICATION The following information must be provided in order to process your application. Name:___________________________________ Telephone: ___________________________ Address: ______________________________________________________________________ Street City State Zip Code Home Owner: [ ] Yes [ ] No Rent: [ ] Yes [ ] No Access to: Driveway Garage Carport Off-Street Parking: [ [ [ [ ] Yes ] Yes ] Yes ] Yes [ [ [ [ ] No ] No ] No ] No Vehicle(s) Identification Number:___ ______________________________________________ Vehicle(s) License Plate Number:__________________________________________________ By signing below you declare that you have not willingly or knowingly made a false statement or given information which you know to be false. ____________________________________________ Signature __________________________ Date Copies of the following documents must be submitted in order to process your application. • Drivers License for handicap person, guardian/parent, or care taker (If handicap person is a minor you must submit proof of age and guardianship) (If handicap person is not the driver, the person who drives must reside at the same address) Vehicle(s) Registration Disabled Person ID Electric and Gas Bill, Water Bill, Tax Bill, Cable Bill ,Telephone Bill , or any bill or mail that has the handicap persons name and address (must submit two different items as proof of residency) Windshield Placard that hangs on the rear view mirror issued by Motor Vehicles (only applies for vehicles that do not have handicap license plates) • • • • In addition, the applicant shall include a Physician’s form providing the following: Name of applicant and date of last examination. An indication of whether or not the applicant has a permanent or temporary disability; if temporary, then the date of expected recovery. Physician certification stating he/she has personally examined the above named applicant and that the information presented in this form is accurate. Physician printed and signed name, current date, address and telephone number, professional license number, and authorizing state. RESIDENTIAL HANDICAPPED PARKING PHYSICIAN’S FORM Applicants Name:_______________________________________________________________ Address: ______________________________________________________________________ Street City State Zip Code Permanent Disability: Temporary Disability: [ ] Yes [ ] Yes [ ] No [ ] No Date of Expected Recovery: ________________ Physicians Name: ________________________________ Telephone: _____________________ Address: ______________________________________________________________________ Street City State Zip Code Physicians Professional License Number: ________________________ Authorizing State: _________________ I have personally examined the above named applicant and the information presented in this form is accurate. _______________________________________________ Signature ___________________________ Date