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APPLICATION FOR HANDICAPPED PARKING SPACE PERMIT

Borough of Clifton Heights

New Application Renewal Application
Name:
Email:
Address:
Phone:
Handicapped License Plate #:
Handicapped Placard #:
Reason for requesting a Handicapped Parking Space Permit: Applicant is wheelchair-confined
Person requesting permit is caring for an individual who has a severe physical
Applicant is unable to walk a distance of 50 feet (Applicant may be asked to perform this and/or produce documentation verifying this condition)
Applicant has severe cardiopulmonary insufficiency that requires the use of ambulatory oxygen
Applicant requires the use of prosthetic devices that restricts normal ambulation
Applicant has other physical or mental limitations that are severe enough to warrant a handicapped parking space (please specify in Other)
Other:
Date:
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