CLASS 1 PARKING LABEL

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CLASS 1 PARKING LABEL Powered By Docstoc
					                            CLASS 1 PARKING LABEL
 * NEW APPLICATION / RENEWAL FOR DRIVERS WITH DISABILITIES
                 (Please circle where applicable)

TO BE COMPLETED BY APPLICANT
(PERSONAL VEHICLE OWNER)

I declare that the information given is true and correct. I understand that if I have wilfully
suppressed any or provided false information, the car park label, if issued, will be revoked.

I understand that the Administrator reserves the right to reject my application and that the
reason(s) for rejection need not be disclosed.

I undertake to abide by the prevailing Terms and Conditions of the Parking label failing
which the label will be revoked.

Applicant Name *      : _________________________________________________

NRIC Number *         : |__|__|__|__|__|__|__|__|__|

Date of Birth *       : |__|__|__|__|__|__|

Residence Address * : _________________________________________________

                        _______________________Postal Code __ __ __ __ __ __

E-mail Address        : _________________________________________________

Home Tel *            : |__|__|__|__|__|__|__|__|

Office Tel            : |__|__|__|__|__|__|__|__|

HP *                  : |__|__|__|__|__|__|__|__|

Vehicle Registration Number *: ____ ____ ____ ____ ____ ____ ____ ____

Vehicle IU Number * : ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Is the vehicle adapted for your own use?                                  * Yes / No

Are you a season parking holder at HDB car park?                          * Yes / No

Do you need to keep your car door wide open to get in and out of the car? * Yes / No


Applicant Signature: _______________________ Date Signed:                d d m m y y



* Mandatory field
                                           CONFIDENTIAL                              Page 1 of 4
 Important Note


1.     The Disability and Mobility Report must be completed by a qualified and licensed
       medical doctor (with MBBS title).


2.     The application together with the Disability and Mobility Report and the following
       documents should be forwarded to the Administrator by fax or post as follows:

       a      Valid driving license(s) – front & back
       b      Identity Card / FIN card and passport (foreigner) for applicant and co-
              applicant (Class 2 only) – front & back
       c      Vehicle registration card(s) or e-Vehicle registration card(s) – up to 3 cars
              (onto ONE label only)
       d      Authorisation letter(s) from vehicle owner if the vehicle does not belong to the
              applicant
       e      Document stating the exemption of ARF, if applicable
       f      Return of expired label, if applicable



                               Centre for Enabled Living
                                 298 Tiong Bahru Road
                                  #03-01 Central Plaza
                                   Singapore 168730
                                  Mainline: 6593 6437
                                    Fax: 6270 7024
                                Email: schemes@cel.sg
                               Website: http://www.cel.sg




FOR OFFICIAL USE ONLY

Disability: _____________________                   Effective Date _______________________

Decision: * New / Renewed / Rejected                Expiry Date _________________________

* Delete where applicable.




                                         CONFIDENTIAL                                Page 2 of 4
              CAR PARK LABEL FOR THE PERSON WITH DISABILITY
                           DISABILITY AND MOBILITY REPORT
                                      (To be completed by Doctor)




Applicant Name     : _________________________________________________________________

NRIC No.: ________________________________________________________________________



PART I: ASSESSMENT BY MEDICAL DOCTOR (to be completed by Doctor)




Information Needed                               Remarks


Date of Assessment



Diagnosis



Nature of disability



Date/Year of onset of disability


Please indicate whether disability is
temporary or permanent


For temporary disability, please
indicate prognosis for recovery and
timeframe




                                              CONFIDENTIAL                    Page 3 of 4
PART II: ASSESSMENT CHECKLIST (to be completed by Doctor)

IF NOT USING MOBILITY AIDS, please complete SECTION (A),
IF USING MOBILITY AIDS, please complete SECTION (B)

SECTION (A)                 NOT USING MOBILITY AIDS                                Please Circle

Mobility Status             The person with disability requires the extra            Yes / No
                            parking space to open the car door fully to get in
                            and out of the car.


SECTION (B)                 USING MOBILITY AIDS                                    Please Circle

                                     Mobility Status

                            Totally dependant on the wheelchair due to               Yes / No
                            paralysis from chest downwards

                            Person can walk with the help of mobility aids           Yes / No
                            such as crutches or walking sticks, but using
                            wheelchair always for outdoor mobility
1 Using Wheelchair
                            Person has severe balancing problem while                Yes / No
                            walking and using wheelchairs for all outdoor
                            mobility purpose

                            Person with physical disabilities such as                Yes / No
                            amputation of one or both lower limbs using
                            wheelchair as a main mode of mobility

                            Person using bilateral crutches or sticks for            Yes / No
2 Using crutches or
walking sticks (for more    mobility
than 6 months)
                            Person using unilateral crutches or sticks and need      Yes / No
                            the support of a fully open car door to assume
                            standing position.

                            Person using bilateral crutches or sticks for            Yes / No
                            mobility

                            Person using unilateral crutches or sticks and need      Yes / No
                            the support of a fully open car door to assume
3 Using Orthosis or
                            standing position.
Prosthesis
                            Person using unilateral above Knee Orthosis or           Yes / No
                            Prosthesis and need to extend the leg out the car to
                            lock the knee joint.

                            Person using bilateral below Knee Orthosis or            Yes / No
                            Prosthesis but need to use mobility aids for
                            outdoor mobility purposes.




Name of Doctor              Doctor Signature             Phone No                       Date
Stamp of Clinic/ Hospital                CONFIDENTIAL                                    Page 4 of 4