Eddystone Police Department

 

Overnight Parking Permit Application

 

Owner: ___________________________________________________

 

Address: __________________________________________________

 

City: _____________________________________________________

 

State: _______________             Zip Code: ____________________

 

Vehicle Make: _____________________________________________

 

Model: ________________________  Year : __________________

 

Vehicle Color: _____________________________________________

 

Registration (Tag #) _________________________________________

 

Registration Expiration: ______________________________________

 

Insurance Company: _________________________________________

 

Insurance Effective Dates: ______________  to ________________

 

State Inspection/Emission Expires: _____________________________

 

Contact Phone # _______________________________________

 

 

_________________________________       ____________________

                     Applicant’s Signature                                                                  Date                

 

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           OFFICIAL USE ONLY:           (Blue) Sticker # ________________

 

APPROVED ______________                         DENIED ________________

 

_________________________________       _____________________         

                        Chief of Police or Designee                                                             Date          

 

 

** APPLICANT WAS NOTIFIED ABOUT PLACEMENT OF STICKER __________