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2. Borough of West Chester

   Handicapped Parking Permit

4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Phone Number: *
16. Email Address*
18. State Issued Placard Number*
20. Documentation Requirements

    Please upload a copy of each of the following:

22. Upload Registration
24. Upload Handicapped Placard
26. Upload Driver's License
28. Signature*

    Your request will not be considered complete without ALL supporting documentation.

30. OFFICE USE ONLY - DO NOT ENTER INFORMATION BELOW THIS LINE

34. Registration
36. ID CARD
37. PLACARD
39. Manager's Name
41. Agenda Date
42. Deceision

    1. Approved
    2. Denied
44. Notes
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field