Handicap Sign Permit Application

JERMYN BOROUGH
440 JEFFERSON AVENUE JERMYN, PA. 18433

Phone 570- 876-0610 Fax 1-570-876-0204

Email: jermynborough@jermynpa.com
Handicap Sign Permit Application

A HANDICAPPED SIGN WILL NOT BE PROVIDED IF THE APPLICANT HAS OFF-STREET PARKING .

The applicant must have a physical impairment ,such as loss of the use of lower extremity or a cardiopulmonary condition which restricts movement or requires the use of a wheelchair, crutches, walker or similar device.
NAME:
Telephone:
ADDRESS:
Vehicle information ( year, make):
Vehicle Registration Plate HP #:
Expiration DATE:

MonthDayYear
Date
1. Does applicant use a wheelchair, crutches, walker or similar device?
Type a question
2. If no to number 1 ,does applicant have a cardiopulmonary condition which results in restriction of movement?
3. Does applicant have arthritis?
Note: Penalty for any fraudulent use of the handicapped space will result in immediate termination of such privilege. If you have a PLACARD please include a copy with application.
Applicant Signature (or Parent/Guardian if Applicant Under 18)

Clear
Date

MonthDayYear
Date
Should be Empty:

JERMYN BOROUGH