ACROD Organisation Apply for a Permit · Customer Self-Service

Applicant

Information

Organisation Name

ABN

Linking Code (if known)

Your Title

Given Names

Surname

Position

Mobile Phone

Telephone

Fax

Postal Address

Street 1

Street 2

Suburb

Postcode

State

Country

Different Business Address?

NoYes

Business Address

Street 1

Street 2

Suburb

Postcode

State

Country

Service Information

Your organisation

Type

Other

Taxi Plate Numbers

How many people do you provide services to

Who are unable to walk and always require the use of a wheelchair

***

Whose ability to walk is severely restricted by a permanent or temporary medical condition or disability

***

Vehicles you operate

How many modified vehicles are operated by your organisation, e.g. vans with hoists, ramps, handrails etc?

***

How many other vehicles operated by your organisation will the Australian Disability Parking Permits be used in?

***

Securing your permits

Is there a secure place for your permits to be stored when not in use?

NoYes

Specify

Other information

Do you have policies in place to ensure the Australian Disability Parking Permits are used correctly by staff?

NoYes

Permits

Number of permits requested

***

Authorisation

Organisation Statement

I have read all the information contained within this form, and verify that it is correct to the best of my knowledge.

I verify that our organisation will only use the Australian Disability Parking Permit(s) when staff or volunteers are transporting people who fit the eligibility criteria.

I understand and accept the ACROD Parking Program Permits - Organisation Terms and Conditions regarding the rights and responsibilities of permit use.

CEO/Principal/Business Owner

Given Names

Surname

Position

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