Village of Cedarhurst/State Handicapped Parking Permit Application

200 Cedarhurst Avenue, Cedarhurst, NY 11516

Part  I (To be completed by applicant) PLEASE PRINT

 

Applicant Name _________________________________________________________________

 

Address ________________________________________________________________________

                             You must provide proof of residency if name does not appear on our roll

 

Date of Birth _____________  Telephone # ___________________   _______________________

                                                                                    Home                                         Business

 

Drivers License I.D. # _______________________________

I hereby certify that the above statements are true and authorized by the physician named in

Part II

To furnish any information to this office concerning the diagnosis, prognosis, and treatment of my prescribed condition. I further acknowledge that I have read and understand the conditions of this application and the Handicapped Parking Permit, and I shall observe and comply with same.

Date _________________  ______________________________

                                                Signature of Applicant or Guardian

 

Part II (To be completed by Medical Doctor or Doctor of Osteopathy)

Physician’s Name ___________________________ License # ____________________________

 

Address ________________________________________ Phone # _________________________

 

________________________________ has one or more of the following impairments.

                Answer all four questions

  1. Please check applicable condition(s)

            ______ limited or no use of one or more lower limbs

           

            ______ neuro-muscular dysfunction which severely limits mobility.

 

            ______ physical or mental impairment or condition which is other than those specified                            above, but imposes unusual hardship in utilization of public transportation                                                  facilities and such condition prevents applicant from getting around without great difficulty.

            ______ a blind person

 

  1. Please describe handicapped condition __________________________________________________________________________________________________________________________________________________________________
  2. Describe limitations in ambulation (include use of walking aids) __________________________________________________________________________________________________________________________________________________________________

 

  1. This condition is _______ Permanent _______ Temporary  If Temporary please indicate approximate length of time your patient will require the Permit _________

                                                                                                                    Months

I am an MD or a DO, licensed to practice in New York State, and in my professional opinion, I believe the applicant’s condition does warrant a Handicapped Parking Permit.

                                                                                                ___________________________________

                                                                                               Signature of Physician (no stamp accepted)

                                       

                                                                                                                        Date ________________