CITY
OF
ALIQUIPPA
581 FRANKLIN AVENUE
ALIQUIPPA, PA 15001
APPLICATION FOR HANDICAPPED PARKING
(RESIDENTIAL ONLY)
Please Print
Applicant's Name:
Address:
Phone: Date:
This Application is: A Renewal A New Application
Location of Space Requested:
If Different Location than Address, Please Explain Why:
Are any of the following available at the requested location?
Off Street Parking
Driveway
Garage
If Yes, provide explanation why it cannot be utilized:
Nature/Severity of Disability:
Name and Address of Vehicle Owner (as listed on Vehicle Registration):
HP
(Handicap) or
SDV
(Severely Disabled Veteran) License Plate No.:
Vehicle Make: Vehicle Model:
Vehicle Year:
VIN:
Is this vehicle modified to accommodate your disability? Yes No
If Yes, please explain:
Applicant's Signature Signature
&
Relationship of Person Completing
Application
if
not Applicant
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FOR CITY USE ONLY
City Official: Date:
DISAPPROVED FOR THE FOLLOWING REASON(S):
Falsification of Information
Off-Street Driveway
parkinglgarage appears to be available at residence
-
Providing HP Reserved Parking may create an undue inconvenience to others
-
Adequate HP Reserved Parking currently exists near residence
-
No HP (handicap) or SDV (severely disabled veteran license plate)
Current parking restrictions prohibit parking at this location
Other
