FOR BOROUGH OFFICE USE ONLY
FOR BOROUGH OFFICE USE ONLY:
RECEIVED_____________________
MEETING DATE________________
APPROVED_____________________
DENIED________________________
REMARKS______________________
BOROUGH OF TAMAQUA
320 EAST BROAD STREET, TAMAQUA, PA 18252
APPLICATION FOR HANDICAPPED PARKING SPACE PERMIT
NEW APPLICATION_____________________ RENEWAL APPLICATION______________
TEMPORARY SPACE ______________ (temporary, short-term disabilities, see Section A, #7)
PERMANENT SPACE ______________ (permanent, life-long disabilities, see Section A, #5)
NAME_______________________________________________________________________________
ADDRESS___________________________________________________________________________
_____________________________________________________________________________________
PHONE ________________________________ CELL PHONE ________________________________
HANDICAPPED LICENSE PLATE#_____________________ PLACARD#_____________________
ATTACH A MEDICAL REPORT (NOT JUST A PRESCRIPTION) FROM YOUR TREATING PHYSICIAN THAT DESCRIBES YOUR HANDICAP AND/OR DISABILITY AND HOW THIS CONDITION AFFECTS YOUR ABILITY TO UTILIZE THE CURBSIDE PARKING OFFERED TO THE GENERAL PUBLIC.
WHERE DO YOU WANT A HANDICAPPED PARKING SPACE? (ATTACH DIAGRAM, IF POSSIBLE)________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
REASON FOR REQUESTING A HANDICAPPED PARKING SPACE PERMIT:
_____ APPLICANT IS WHEELCHAIR CONFINED.
_____ APPLICANT REQUIRES THE USE OF PROSTHETIC DEVICES THAT RESTRICT NORMAL AMBULATION.
_____ APPLICANT HAS OTHER PHYSICAL OR MENTAL LIMITATIONS SEVERE ENOUGH
TO WARRANT A HANDICAPPED PARKING SPACE (EXPLAIN AND BE SPECIFIC)
______________________________________________________________________________
______________________________________________________________________________
Fee for New or Renewal Applications (must be submitted with application): $25.00
All disabled veterans of any branch of the armed forces are exempt from all fees.
Make checks or money orders payable to: “Borough of Tamaqua”
Under the criminal penalties prescribed by Section 4904 Of the PA "Crimes Code" (18 Pa. CSA S-4904) for making a false statement to a public official or public body. I hereby verify to the Borough of Tamaqua that the facts set forth in this Application are true and complete to the best of my knowledge.
_________________________________________________ _______________________________
SIGNATURE DATE
................
................
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