2. This application form requests information which will be used to determine your eligibility for issuance of a permit. Failure to provide the information will result in a denial of the permit.
4. Instructions To Applicant:
   The applicant must deliver a completed application to the Department of Central Services at 1801 Kentucky Street, Michigan City, Indiana accompanied by all items required by this application. The application may be delivered in person, U.S. mail, or by facsimile at 219-873-1565. Once the application is complete, the Department of Central Services shall, within a reasonable time and no later than 30 days from receipt of a fully completed application, grant or deny the permit so applied for, subject to the following conditions:
6. 1. No applicant shall be granted a permit for more than one (1) reserved space adjacent to or directly across the street from his place of residence.
8. 2. No applicant who has access to parking on their residential property or off-street parking at his place of residence shall be granted a permit, with the exception that the Department of Central Services may, in its discretion, grant a permit to an applicant who is able to demonstrate that the location of such off-street parking renders it unduly burdensome for him to utilize the same.
10. 3. Each permit granted shall be assigned an identification number.
12. If the application is approved, the Department of Central Services will issue to the applicant a reserved space permit with an identification number and install a sign restricting use of the space to the permit holder only, which sign shall show thereon the holder’s permit number. If a permit is denied, the Department of Central Services will provide written notice to applicant. Within 30 days after a permit has been denied by the Department of Central Services, the applicant may appeal to the Board of Public Works and Safety by filing a written request with the Board that it review the denial of the permit. The decision of the Board of Public Works & Safety is a final decision.
14. First Name*
15. Last Name*
17. Street Address*
18. Suite or Apartment Number
20. Mailing Address
    (if different from street address)
22. City*
23. State*
24. Zip Code*
26. Primary Phone*
27. Secondary Phone
29. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
30. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
32. Email Address*
33. Fax Number
35. Date of Birth*
    Date of Birth
36. Driver's License Number:*
37. State Issuing License:*
39. Documentation*

    Please provide documentation which includes vehicle registration and check below which applies to the applicant

    1. I have been issued a disabled person placard for a permanent disability I.C. 9-14-5
    2. I have been issued a disabled person license place I.C. 9-18-22
    3. I have been issued a disabled veteran license plate I.C. 9-18-22
41. Year/Make/Model*
42. VIN Number*
43. License Plate Number*
44. Issuing State*
46. Will the applicant be seeking parking space across the street from his place of residence? *

    1. Yes
    2. No
48. If yes, please state the name(s) and address(es) of the legal owners of the property:
50. Has applicant been able to secure consent from the legal owner of the real estate in front of which the applicants parking space will be located?*

    1. Yes
    2. No

    If yes, the legal owners must provide their consent in writing and the consent must be attached to this application. If no, provide the following information:
52. Name of Legal Owner of Property in front of which applicant is requesting a parking space:
54. Street Address of Said Property
55. Suite or Apartment Number
57. City
58. State
59. Zip Code
61. The Department shall refer the application to the Clerk’s Office, who shall provide the legal owner with at least ten (10) days’ notice that this matter will appear for consideration by the Board of Public Works & Safety.
63. Copy of Applicant’s Vehicle Registration
65. Copy of placard permanent disability placard issued pursuant to I.C. 9-14-5
67. Written consent from the legal owner of the real estate in front of which the applicants parking space will be located, if applicable.
69. 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.
71. Electronic Signature
76. Did Applicant Provide Proof of Vehicle Registration?

    1. Yes
    2. No
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit Submit and Print

* indicates a required field