NWT DISABILITIES COUNCIL. Parking Placard ApDlication Form Please Note: Applicants must sign off on the Rules Governing the Use of Parking Placards.
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1 6 V C NWT DISABILITIES COUNCIL B-321 Old Airport Road Yellowlcnife, NT X1A 3T3 Ph: (867) or Fax: (867) admin@nwtability.ca Parking Placard ApDlication Form Please Note: Applicants must sign off on the Rules Governing the Use of Parking Placards. Part 1: To Be Completed by the Applicant: Name: Mailing Address: Address: Phone: (home) (work) Birth Date: DO MM YY Male Female Driver s License Number: (If Applicable) My Disability is: To Assist me, I use: Cane, Wheelchair, or Name of Health Care Professional (Doctor, Nurse Practioner Community Health Nurse, Occupational Therapist, or Physiotherapist) Declaration: I declare that the above infonnation is true and correct. Signature of Applicant: Date: For Office Use Only Placard Number: Date Issued(DD/MM/YY) Expiry Date: (DD/MM/YY) Issued By: Previous No: Al Page 1 of 2
2 V NWT DISABILITIES COUNCIL 2,Q B-321 Old Airport Road Yellow*nife, NT X1A 3T3 Ph: (867) or Fax: (867) admin~nwtabiiity.ca Part 2: To Be Completed by an Attending Physician or Nurse Practitioner. (For the purpose of this application, in a community where there is no Attending Physician or Nurse Practitioner, a Community Health Nurse, Occupational Therapist or Physiotherapist may complete Pad 2 of this form. Thank you in advance for ensuring that only those who qualify receive a placard.) ~ The applicant has a permanent disability and requires a mechanical mobility aid. The mechanical aid required is a The applicant has a physical disability resulting in an inability to walk a distance of 100 meters. This disability could be classified generally as: (i.e.: multiple sclerosis, arthritis, head disease, asthma) In your words, describe how this condition(s) impairs this person s mobility: I recommend a: U Temporary Placard U Permanent Placard If a Temporary Placard is recommended, indicate length of time needed: U 2 weeks U 1 month U 6 weeks U 3 months U 6 months a Other Certification: I hereby certi& that, to the best of my knowledge, the above information is true and correct. Physician or Nurse Practitioner: (signature) (print name) If you would like information on how to make a tax-deductible donation to the NWT Disabilities Council, please call (867) or outside Yeliowknife at (toll free) Al Page 2 of 2
3 qco~ 2.01.OO.A2 Rules Governing the Use of Parking Placards Page 1 of 5 General: All parking placards issued by the NWT Disabilities Council are the sole property of the Council and shall be surrendered at the request of the Council. Temporary Placards: The expiry date is printed on the front of your placard. The expiry date of your temporary placard is determined by your doctor or nurse practitioner. Expiry dates cannot be extended. Only your physician or nurse practitioner may authorize another temporary placard by submitting another application. Permanent Placards: Your signature is required (in permanent marker) on the back of your placard in order to validate your placard. Permanent placards are re-issued every two years. The expiry date is marked on the front of your placard. Do not obscure or remove the registration number on the front of your placard. The Council reserves the right to issue parking placards to agencies directly involved in the transfer of persons with disabilities. Date Date Revised: Next Revision Approved by Board of Issued: Date: Directors:
4 00 LDoc lfr 4! 2.01.O0.A2 Rules Governing the Use of Parking Placards Page 2 of 5 Rules Applying To All Parking Placards: The Placard: The parking placard is issued to a person with a mobility disability. The placard may be moved from vehicle to vehicle as required to assist the person with a disability. Parking placards are recognized by most international jurisdictions and can be used outside the Northwest Territories where permitted. NWT Parking placards are issued to NWT residents only. If you terminate your residency from the NWT during the valid period of the placard you must advise the Council of your move and register with the appropriate authority in the new jurisdiction where you reside for a new placard. Responsibilities: The parking placard is issued to you only. Any person not involved in the direct and immediate process of physically assisting you may not use it. Date Issued: Date Revised: Next Revision Date: Approved by Board of Directors:
5 QeC,, 1$ ~ _~. ~ A2 Rules Governing the Use of Parking Placards Page 3 of 5 The use of the parking placard does not in any way exempt you from obeying other parking laws. Some municipalities give special consideration to persons with disabilities (i.e. City of Yellowknife Metered Parking Pay Exemption). Enquiries on parking privileges for persons with disabilities should be directed to the local parking enforcement authority. It is the responsibility of the placard holder to advise the Council of any change of address or contact information, including phone number. Your placard should be hung from the rear view mirror of the vehicle you are traveling in. The registration number (as applicable) and expiry date must be visible from outside the vehicle. When the vehicle is not in use for the express purpose of assisting the permit holder, you are encouraged to remove the placard from display. You are responsible for informing the NWT Disabilities Council if your placard has become lost or stolen or if it needs replacing for any reason, including damage. You are responsible for any misuse of the parking placard. Designated parking spaces for persons with disabilities are not to be used for parking while you are at work. Date Issued: Date Revised: Next Revision Date: Approved by Board of Directors:
6 !,Vj 2.01.OO.A2 Rules Governing the Use of Parking Placards Page 4 of 5 Designated parking spaces or metered parking spaces provided by the municipality are not to be used as a substitute for a commercial car lot or lack of personal vehicle space. Designated parking spaces are for short-term use only. Os Ouc. ;~.-t ~ Designated parking spaces are not to be used for extended periods of time (i.e. over 2 hours). If you are having a Good Day and do not require the use of a designated parking space, please use a non-designated space. A vehicle operator in the direct and immediate process of dropping you off or picking you up may utilize a designated parking space provided that the parking placard issued to you is displayed in the prescribed manner. Please contact local parking enforcement authorities or the NWT Disabilities Council if you wish to report abuse of a designated parking space. Enforcement of on-street parking falls under the jurisdiction of the local parking enforcement authority. Date Issued: Date Revised: Next Revision Date: Approved by Board of Directors:
7 qqo~ ~. t.! j 2.O1.OO.A2 Rules Governing THE NWT DISABILITES the Use of Parking COUNCIL Placards Page 5 of 5 Please fill in and sign both copies of the acknowledgement block below and return the bottom acknowledgement to the NWT Disabilities Council Office. I hereby acknowledge receipt of a copy of the Rules Governing the use of Parking Placards and agree to follow and obey these rules. I also acknowledge that the parking placard issued to me is for my personal benefit only and that the Council has the right and ability to rescind the parking placard issued to me. Name: Date: Signature: Placard Registration No.: Witness Signature: K I hereby acknowledge receipt of a copy of the Rules Governing the use of Parking Placards and agree to follow and obey these rules. I also acknowledge that the parking placard issued to me is for my personal benefit only and that the Council has the right and ability to rescind the parking placard issued to me. Name: Signature: Date: Placard Registration No.: Witness Signature: Date Date Revised: Next Revision Approved by Board of Issued: Date: Directors:
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