Nassau Parking Application PDF Details

Download the Nassau parking application form to apply for a parking permit. The form is available in PDF format and can be filled out and submitted online or by mail. Review the eligibility requirements and instructions before submitting your application. You will need to provide documentation proving your residency or business ownership in Nassau County. Parking permits are valid for one year and can be renewed online or through the mail. Fees vary depending on the type of permit you are applying for. For more information, visit the Nassau County website.

You will see info about the type of form you want to submit in the table. It can show you how much time it should take to complete nassau parking application, exactly what fields you need to fill in and some additional specific details.

QuestionAnswer
Form NameNassau Parking Application
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnassau county handicapped application, nassau handicapped parking, form for handicap parking, nassau county handicap parking application

Form Preview Example

NASSAU COUNTY OFFICE FOR THE PHYSICALLY CHALLENGED STATE HANDICAPPED PARKING PERMIT APPLICATION

60 CHARLES LINDBERGH BOULEVARD, UNIONDALE, N.Y. 11553 (516) 227-7399

PART I PERSONAL INFORMATION (To be completed by disabled person)

Name of Disabled Person_____________________________________________________________________________________

(please print )lastfirstmiddle initial

Address___________________________________________________________________________________________________

house number, street (NO P.O. Box)

city

zip code

county

state

HomeTelephone_____________________________

Date of Birth ______________________

Male

Female

Do you have a handicapped license plate? No_________ Yes_________ If yes, License Plate No.___________

Current Drivers License ID Number/Non Drivers License ID Number Do not have Drivers License/Non Drivers License

I hereby certify that the above statements are true and authorize the physician named to furnish any information requested by the Nassau County Office for the Physically Challenged concerning the diagnosis, prognosis and treatment of my described condi- tion. I further acknowledge that I have read and understand the conditions of this application and the Handicapped Parking Permit, and shall observe and comply with same.

Date

SIGNATURE OF APPLICANT OR GUARDIAN

PART II MEDICAL CERTIFICATION INFORMATION (To be completed by a New York State licensed medical physician).

Name of Physician

 

 

 

Phone #

Address

 

 

 

 

 

 

 

 

 

 

 

Physicians’s

Name of Patient

 

 

NYS Practicing License #

 

 

Please Check and describe below applicable condition(s):

“Severely Disabled Person”. shall mean any person who has any one or more of the following impairments, disabilities or condi- tions which are permanent in nature.

(a)_____ Has limited or no use of one or both lower limbs; (State disability and describe below:)

(b)_____ Has a Neuro-muscular dysfunction which severely limits mobility; (state disability and describe below)

(c)_____ Has a physical or mental impairment of condition which is other than those specified above, but is of such nature as

to impose unusual hardship in utilization of public transportation facilities and such condition is certified by a physician duly licensed to practice medicine in this state as constituting an equal degree of disability (specifying the particular condition) so as to prevent such person from getting around without great difficulty in accordance with subdivision two of this section; or

(d)_____ A legally blind person

 

State Permanent diagnosis:

 

Please describe handicapped condition:

 

Temporary ?: _______

How long is

_______ Doctor must state walking device used ______________________

 

 

Permit needed?:

TEMPORARY DISABILITY: A temporarily disabled person is any person who is unable to ambulate without the aid of an assisting device, such as a brace, cane, crutch, prosthetic device, wheelchair, walker or other assistive device. (temporary permits are issued for periods of six months or less). New application required after that.

State temporary diagnosis:_________________________________________________________________________________

I am an MD licensed to practice in New York State, and in my professional opinion, I believe the applicant’s mobility impairing condition does warrant a handicapped Parking Permit, according to the above New York State definition of

“SEVERELY DISABLED.”

Yes________ No_________

 

 

Date: ___________________

 

 

 

 

 

 

 

 

SIGNATURE OF PHYSICIAN (No stamps accepted)(MD/DO/DPM/NP)

 

 

 

 

 

 

 

 

 

 

 

 

For Office Use Only

 

 

 

 

 

Permit No. _____________________

Date Issued ________________

Expiration Date _____________

Permanent

Temporary

HP4594 5/79/ Rev. 11/08

See Reverse Side

INSTRUCTIONS FOR APPLICATION

1.MUST BE A NASSAU COUNTY RESIDENT.

You are eligible for a permit if you are a resident of Nassau County who has one or more servere disabilities that impair your mobility.

All applications must have a Nassau County street address (No Post Office Boxes).

2.All applications must be fully completed and properly executed.

All questions must be answered and Medical Certification MUST be completed by a New York State Practicing Licensed Medical Doctor. All Applications must be signed not stamped.

*****NO CHIROPRACTOR *****

3.All permits are issued in the name of the person with the disability, therefore all Information on application must pertain to the disababled applicant.

You do not have to be the driver . Children and non drivers can apply for a permit. Application must be in the name of the person with the disability.

4.The Department of New York State Motor Vehicles requires the disabled person’s

New York State Drivers License Client ID number or on a NYS ID card to be on the permit. Enclose a copy of disabled applicants ID (not the person driving them) with this Completed application.

5.COPIES OR FAXES of Applications will result in immediate denial.

6.To expedite the issuance of your permit upon approval, please enclose a self-addressed (number 10 size) envolope.

7.Any FALSE statement on the application by the applicant or by the doctor will result in refusal to issue a permit.

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