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SPECIAL NEEDS ASSISTANCE FORM

  1. needs assistance header
  2. APPLICANT MEDICAL INFORMATION
  3. Does Applicant Have a Current Handicapped Parking Placard?
  4. Check if Severely or Permanently Disabled
  5. PLEASE CHECK BELOW WHICH BEST DESCRIBES DISABILITY
  6. MUST USE DEVICE FOR ASSISTANCE (please check which device)
  7. Please explain:

  8. ABILITY TO WALK IS SEVERLEY LIMITED TO:
  9. * As defined by American Heart Association ** As defined by the New Jersey Commission for the blind
  10. OXYGEN (TANK OR DELIVERY SYSTEM)
  11. EMERGENCY CONTACTS & PHONE NUMBERS:
  12. NAME, ADDRESS & TELEPHONE NUMBER OF PERSON SUBMITTING FORM IF DIFFERENT FROM SPECIAL NEEDS INDIVIDUAL:
  13. APPLICATION MUST BE REVIEWED EVERY TWO YEARS
  14. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  15. COMPLETE THIS FORM & SEND ELECTRONICALLY BY USING THE SUBMIT BUTTON. YOU CAN ALSO PRINT & EMAIL IT TO YOURSELF FOR YOUR RECORDS.

  16. Leave This Blank:

  17. This field is not part of the form submission.