INC. VILLAGE OF CEDARHURST 2012 Resident Application for Parking Permit

Under Penalty of Perjury, the Undersigned Affirms as Follows:

NAME__________________________________________________________________

ADDRESS ______________________________________________________________

TELEPHONE # _________________________________________________________

BUSINESS PHONE # _____________________________________________________

Parking Permit will be used on the following vehicle:

MAKE__________________ YEAR____________ PLATE #_____________________

VEHICLE ID#___________________________________________________________

It Is Understood That The Permit Is Void If Attached To Any Other Vehicle

PARKING PERMIT#_______________________ DATE_______________________

SIGNATURE___________________________________________________________