Handicap Parking Request Form

Handicap Parking Request Form (#65)

First Name

Middle Name

Last Name

Mailing Address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone

Date of Birth

Email Address

Driver License Number

Application Type

Permanent Placard

Temporary Placard

Travel Parking Placard

Disabled Person License Plate

License Plate Number

Vehicle Identification Number (VIN)

Vehicle Make

Vehicle Year

Please attach document from state licensed medical physician to certify disability.

Choose File

The information I have entered is truthful to the best of my knowledge.