NORTH BERGEN PARKING AUTHORITY

RESIDENTIAL PARKING PERMIT APPLICATION

7224 Bergenline Avenue

North Bergen, NJ 07047

Phone: (201) 869-6200 Fax: (201) 453-8686

 NEW APPLICATION  RENEWAL

PERMIT NO. PERMIT NO. PERMIT NO.

NAME/

Nombre:

ADDRESS/

Direccion:

CITY/ STATE/ ZIP CODE/

Ciudad: Estado: Codico Postal:

HOME PHONE #/ WORK PHONE #/

No. de Telefono: No. de Trabajo:

FAX #/ E-MAIL ADDRESS/

No. de Fax: Correo Electronico:

DRIVER’S LICENSE #/

No. de Licensia de Conducir: ___ ___ ___ ___ ___ - ___ ___ ___ ___ ___ - ___ ___ ___ ___ ___

VEHICLE IDENTIFICATION NUMBER (VIN #) /

No. de Circulacion:(1):

(2):

(3):

I CERTIFY THAT UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE./

Yo certifico bajo pena de perjurio que esta informacion es verdadera.

SIGNATURE/Firma DATE/Fecha

WE ONLY ACCEPT CHECK OR MONEY ORDERS PAYABLE TO THE NORTH BERGEN PARKING AUTHORITY / Aceptamos Solamente Cheque o Giro Postal pagable al North Bergen Parking Authority

*********DO NOT WRITE BELOW THIS LINE/No escribir despúes de esta linea********

LICENSE PLATE #

MAKE

MODEL

YEAR

COLOR

PERMIT NO.

DRIVER’S LICENSE ÿ REGISTRATION ÿ UTILITY BILL(S) ÿ LEASE/RENTAL AGREEMENT ÿ OTHER ÿ

UTILITY COMPANY: ACCOUNT #:

UTILITY COMPANY: ACCOUNT #:

APPROVED BY: FEE COLLECTED: $ ÿ CHECK ÿ MONEY ORDER