DEPARTMENT OF AVIATION AND TRANSIT
SPECIAL USE PARKING FORM FOR
INDIVIDUALS WITH MOBILITY DISABILITIES
NAME
ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER
VEHICLE LICENSE PLATE NUMBER STATE
PERSONS/VEHICLES THAT ARE NOT DISPLAYING A SPECIAL HANDICAPPED OR VETERANS STATE ISSUED LICENSE PLATE ATTACHED TO THEIR VEHICLE MUST COMPLETE THE FOLLOWING:
SPECIAL USE PERMIT NUMBER
PERMIT ISSUE DATE PERMIT EXPIRATION DATE
STATE & CITY THE PERMIT WAS ISSUED IN
SIGNATURE OF PERMIT HOLDER
THE FOLLOWING IS TO BE COMPLETED BY APCOA CASHIER
Time and Date In:
Time and Date Out:
Sequence Number
Value of Ticket Before Reduction
Signature of Cashier
ATTACH THIS FORM TO YOUR SHIFT REPORT