Temporary Accessible Parking Parking Application Form

Temporary Accessible Parking Placard Application
DIRECTIONS: This document must be signed and completed on both sides: the front side by a licensed
physician and the backside by the applicant.
DEFINITIONS: Sec. 1-159.1. Person with disabilities. A natural person who, as determined by a licensed
physician, by a licensed physician assistant, by a licensed advanced practice registered nurse, or by a licensed
physical therapist: (1) cannot walk without the use of, or assistance from, a brace, cane, crutch, another person,
prosthetic device, wheelchair, or other assistive device; (2) is restricted by lung disease to such an extent that
his or her forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than
one liter, or the arterial oxygen tension is less than 60 mm/hg on room air at rest; (3) uses portable oxygen; (4)
has a cardiac condition to the extent that the person's functional limitations are classified in severity as Class
III or Class IV, according to standards set by the American Heart Association; (5) is severely limited in the
person's ability to walk due to an arthritic, neurological, oncological, or orthopedic condition; (6) cannot walk
200 feet without stopping to rest because of one of the above 5 conditions; or (7) is missing a hand or arm or
has permanently lost the use of a hand or arm. (Source: P.A. 102-1011, eff. 1-1-23.)
Name of Resident with a Disability:___________________________________________________________________
Diagnosis:_____________________________________________________________________________________________
Check Applicable Disability Duration: _____ 30 Days _____ 60 Days _____ 90 Days
“May not be issued for more than 90 days. Subject to renewal based on continued disability and
submission of new application. ”
I hereby certify that the physical condition of the person with disabilities listed herewith constitutes him/her
as a disabled person as described under ILCS 5/1-159.1.
WARNING: Any person who knowingly misuses or makes a false or misleading statement on an
application can be fined up to $1,000.
PHYSICIANS: Do not sign this form if the named patient does not meet the above definition.
Physician’s Stamp/License Number Required
_______________________________________________________________________________________________________
Physician’s Name & Signature
_______________________________________________________________________________________________________
Physician’s Licence Number
_______________________________________________________________________________________________________
Physician’s Address, City, State
_______________________________________________________________________________________________________
Physician’s Telephone Number
Updated 4/18/2025

-- 1 of 2 --

Resident with a Disability
________________________________________________________________________________________________________
Name of Resident with a Disability
________________________________________________________________________________________________________
Applicant’s Address, City, State & Telephone Number
________________________________________________________________________________________________________
Applicant’s Driver's Licence/ State ID Number (If the applicant does not have an identification card or driver's
license number, then the applicant may use a valid identification number issued by a branch of the U.S. military or a
federally issued Medicare or Medicaid identification number)
I hereby apply for a Person with Disabilities Parking Placard under a statutory provision, (625 ILCS 5/1-159.1)
and certify that my physical condition entitles me to the issuance thereof. I am also aware that the Person
with Disabilities Parking Placard must not be used unless I am the driver or passenger in the vehicle.
_______________________________________________ 	__________________________________________
Applicant’s Signature 	Date
WARNING:
MISUSE OF/OR FALSE APPLICATION FOR THE RESIDENT WITH A DISABILITY PARKING PLACARD can
result in its revocation, a 30-day driver’s license suspension, and a fine up to $1,000. The person with disabilities
must exit or enter the vehicle when parking in areas reserved for such person or when parking at metered
spots.
RETURN THIS COMPLETED FORM TO:
City Clerk’s Office
City of Evanston
909 Davis St, 2nd Floor
Evanston, IL 60201
Phone: (847) 448-8189
FOR OFFICE USE ONLY
_________________________________________________________________________________________________________________________
Placard Number & Expiration Date
_________________________________________________________________________________________________________________________
Issued By & Date
_________________________________________________________________________________________________________________________
New Applicant or For Renewal
Updated 4/18/2025

-- 2 of 2 --