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2. 
4. FULL NAME OF PERSON WHO NEEDS ASSISTANCE:*
6. STREET ADDRESS:*
8. CONTACT PHONE NUMBER:*
10. DATE:*
    DATE:
11. AGE:*
12. D.O.B.*
    D.O.B.
16. APPLICANT MEDICAL INFORMATION
18. Does Applicant Have a Current Handicapped Parking Placard?

    1. YES
    2. NO
19. Placard Expiration Date
    Placard Expiration Date
20. Check if Severely or Permanently Disabled

    1. Yes
22. PLEASE CHECK BELOW WHICH BEST DESCRIBES DISABILITY
24. MUST USE DEVICE FOR ASSISTANCE (please check which device)

    1. CANE
    2. CRUTCH
    3. WHEELCHAIR

    1. PROSTHETIC DEVICE
    2. OTHER PERSON
25. OTHER (if not listed here)

    Please explain:

27. 1. LUNG DISEASE
    2. CARDIAC CONDITION w CLASS III LIMITATION*
    3. CARDIAC CONDITION w CLASS IV LIMITATIONS*

    1. DEAF
    2. HARD OF HEARING
    3. PERMANENT SIGHT IMPAIRMENT**
28. ABILITY TO WALK IS SEVERLEY LIMITED TO:

    1. ARTHRITIC CONDITION
    2. NEUROLOGICAL CONDITION
    3. ORTHOPEDIC CONDITION
30. * As defined by American Heart Association ** As defined by the New Jersey Commission for the blind
32. OXYGEN (TANK OR DELIVERY SYSTEM)

    1. TANK
    2. DELIVERY SYSTEM
34. DESCRIPTION OF DISABILITY OR NEED FOR ASSISTANCE:*
36. EMERGENCY CONTACTS & PHONE NUMBERS:
38. 1. NAME:
39. DAYTIME PHONE:
40. EVENING PHONE:
42. 2. NAME:
43. DAYTIME PHONE:
44. EVENING PHONE:
46. 3. NAME
47. DAYTIME PHONE:
48. EVENING PHONE:
50. NAME, ADDRESS & TELEPHONE NUMBER OF PERSON SUBMITTING FORM IF DIFFERENT FROM SPECIAL NEEDS INDIVIDUAL:
52. FULL NAME:
54. STREET ADDRESS:
56. CITY:
57. STATE:
58. ZIP CODE
60. DAY TIME PHONE:
61. EVENING PHONE:
63. APPLICATION MUST BE REVIEWED EVERY TWO YEARS
65. 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.

    1. I agree.
67. Electronic Signature
68. DATE:
    DATE:
70. Co-Applicant's Signature & Date:
71. DATE:
    DATE:

73. COMPLETE THIS FORM & SEND ELECTRONICALLY BY USING THE SUBMIT BUTTON. YOU CAN ALSO PRINT & EMAIL IT TO YOURSELF FOR YOUR RECORDS.

Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit Submit and Print

* indicates a required field