Application for Accessibility Parking at NC State University
Serving downtown State Government since 1957
State Employee Accessible Parking Request
Disabled or mobility impaired employees may request special parking accommodations. Approval is dependent upon the completion of this application by the employee’s physician and review by the State Parking Division. Submitting inaccurate or falsified information will result in the loss of or no assignment of parking privileges.
|**All FIELDS MUST BE COMPLETED** |
|Name of Individual Requesting Parking: (Please print legibly) |If issued, State Issued Handicap Placard # and DMV |
| |Registration: (please attach a photocopy) |
| | |
| | |
|First Last | |
|Requestor to Answer the Below Questions |
|(1) What accommodation are you requesting? ______________________________________________ |
| |
|(2) How will this accommodation assist you in accessing your work station? __ ____________________ |
|_____________________________________________________________________________________ |
|To be completed by attending physician. |
|(Please type or write legibly using terminology easily understood by non-medical staff) |
|. |
| (3) Please describe the individual’s physical condition and how it requires the need for ADA accessibility parking. |
| __________________________________________________________________________________ |
|_____________________________________________________________________________________ |
| |
|(4) Please describe limitations: _________________________________________________________ |
|_____________________________________________________________________________________ |
|_____________________________________________________________________________________ |
| |
|(5) Please provide any additional information that might be useful in processing this request: |
| __________________________________________________________________________________ |
|_____________________________________________________________________________________ |
|(6) Expected duration of condition: Permanent Temporary From ( / / ) To / / ) |
|Authorizing Physician |
|Physician’s Name: |
| |
|Name of Practice: |
| |
|Office Address: |City/State/Zip: |
| | |
|Phone: |Fax: |
| | |
|Terms and Conditions |
|By signing below, the employee agrees to abide by the terms and conditions stated on page one of this document. |
|By signing below, the Physician is certifying that items (3) – (6) above are true and correct. |
| | |
| | |
| | |
|Employee’s Signature Date |Physician’s Signature Date |
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Please note additional policies and conditions:
➢ Due to limited availability of Downtown State Government parking, it is imperative that accessible parking is assigned only to individuals who truly need this access and meet the ADA guidelines as an individual with a qualifying disability.
➢ All employees will be charged for parking.
➢ Upon transferring to an accessible parking space, the employee’s current parking assignment will be terminated.
➢ Incomplete applications or applications without required signatures will not be processed.
➢ Applications are not valid until approved by the State Parking Division and the assignment of space is completed by the responsible Parking Coordinator.
➢ Please return the completed form to your Parking Coordinator for submission to the State Parking Office.
For Parking Division Use Only
Date Received: ___________ Assignment: Lot ______ Space _______ Start Date: __________ End Date: _____________
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