NAME*

CONTACT NUMBER*

ADDRESS*

BLACK JACK, MO 63033

MAKE AND MODEL OF VEHICLE TO BE PARKED ON STREET*

YEAR*

LICENSE #*

LOCATION*

I, THE APPLICANT, DO HEREBY STATE THAT I RESIDE AT THE ABOVE ADDRESS IN THE CITY OF BLACK JACK AND THE ABOVE STATED VEHICLE(S) ARE REGISTERED TO THE ABOVE LOCATION. I, ALSO HEREBY STATE THAT I AM UNABLE TO FIND REASONABLE PARKING ACCOMMODATINS, AND I THEREFORE MAKE APPLICATION FOR THE PARKING PERMIT(S)

REASON*

BY SUBMITTING THIS FORM I FURTHER AGREE TO COMPLY WITH THE FOLLOWING PROVISIONS OF THE CITY OF BLACK JACK CODE OF ORDINANCES:*

1. VEHICLE(S)MAY BE PARKED BETWEEN THE HOURS OF 2AM AND 6AM ONLY AT THE LOCATION SPECIFIED IN THE APPLICATION. 2. VEHICLE(S) ARE NOT ALLOWED TO BE PARKED IN THE SAME LOCATION WITHOUT BEING MOVED FOR A PERIOD OF MORE THAN 48 HOURS (ORDINANCE NO. 54) 3. PERMIT MUST BE PROPERLY DISPLAYED ON THE DRIVERS SIDE WINDSHIELD, APPLICABLE TO THE AFOREMENTIONED VEHICLE(S) ONLY. PERMIT(S) ARE NON-TRANSFERABLE.

4. IT SHALL BE UNDERSTOOD THAT THE ISSUANCE OF A PERMIT IS TEMPORARY AND CAN BE SUSPENDED OR REVOKED AT ANY TIME. 5. THIS PERMIT MUST BE RETURNED FOR RENEWAL.

LIST TOTAL NUMBER OF VEHICLES IN HOUSEHOLD, INCLUDING MAKE/MODEL, EAR, LICENSE PLATE NUMBER AND EXPIRATION DATE.

MAKE/MODEL*

YEAR*

LICENSE #*

EXPIRATION DATE*

MAKE/MODEL

YEAR

LICENSE #

EXPIRATION DATE

MAKE/MODEL

YEAR

LICENSE #

EXPIRATION DATE

MAKE/MODEL

YEAR

LICENSE #

EXPIRATION DATE

MAKE/MODEL

YEAR

LICENSE #

EXPIRATION DATE

MAKE/MODEL

YEAR

LICENSE #

EXPIRATION DATE

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APPROVED BY CITY OF BLACK JACK / ST. LOUIS COUNTY POLICE ____________________

DISAPPROVED BY CITY OF BLACK JACK / ST. LOUIS COUNTY POLICE ____________________