Transcription of Disabled Parking Permit Application - SAAQ
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Disabled Parking Permit Application - SAAQ
First nameFirst nameRelation to Disabled personLast nameLast name1 - To get around, are you required to use a wheelchair or adapted stroller that is subsidized by the R gie de l assurance maladie du Qu bec (RAMQ)? 2 - If you hold a driver s licence , does it bear Condition P? A Information on Disabled personB Information for Permit eligibilityC assessment (where required, this section must be filled out by the assessment professional identified in Section D )Telephone (work)Telephone (work)Telephone (home)Telephone (home)Address (Number, street, apartment) Disabled person s representative (if applicable)MunicipalityDriver s licence number (if applicable)ProvincePostal codeSexFemaleMaleCorrespondenceEnglishFr enchClaim file number: If you are applying for a Disabled Parking Permit because of a disability resulting from a road accident, check the box below and provide the information note Information provided on this Application may be used in assessing the subject s fitness to drive a motor vehicle.
Information provided on this application may be used in assessing the subject’s fitness to drive a motor vehicle. • The SAAQ does not reimburse the fees that may be charged by an assessment professional. Last name (current) Driver’s licence number (if applicable) Number ... Form to be filled out to claim disabled parking permit.
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