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Tyr$ . RESERVED COUNTY -CITY BUILDING HANDICAP PARKING <br />PERMIT APPLICATION AND AGREEMENT <br />City of South Bend - Board of Public Works <br />k <br />227 W. Jefferson Boulevard, Ste. 1316 <br />South Bend, IN 46601 <br />Applicant Information 1, <br />First Name. / e-) Y) Last Name �n S% t <br />Date of Birth'- a %' �� q Last Four Digits of SS# _531,1 1 <br />Driver's License No. <br />Address 2 Y7 P/ S ` n.s <br />Street <br />Phone <br />Vehicle Information <br />X <br />City State Zip <br />Email h w ' >1-u3X /' 537T<�_ IIA,4 yrX , Cngt <br />Male <br />_(7/_he_v�l Model �' -64(' % /V-,,4 Year <br />Handicap Permit No.2License Plate No. <br />Employer Information <br />Name of Employer v s <br />Supervisor Nam ' 7 <br />Address r� <br />WLocation o ntrance W_ to Bu dg�ing <br />Daily Work Schedule <br />Days: TzA-- _7 <br />Hours S ,_/3D10M <br />No. of Hours Per Week Y <br />Doctor's Note Included <br />Yes V No <br />'5)�Y)V_j <br />FullTime? Yes ANo <br />