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COUNTY OF HAWAII HILO, HAWAII APPLICATION FOR COUNTY FACILITY PARKING LOT STALL ASSIGNMENT Applicant's Name Department Workplace Address: Telephone No. Check one: ❑County Building ❑Aupuni Center ❑West Hawai'i Civic Center ❑Other: A copy of the Department of Public Works County Parking Regulations, dated September 2015, referencing Chapter 24 of the Hawai'i County Code was made available to me. I understand that it is my obligation to read and understand this material and to abide by the rules and regulations established for the orderly utilization of the Hawai'i County Facility Parking area. I also understand that I am governed by these policies and procedures and that the County may change them at will. I understand my monthly parking stall fee must be paid by an automatic payroll deduction from each payroll, or some other pre-approved payment option. Employees who are"qualified individuals with disabilities"and wish to request accessible parking spaces shall submit their requests to their departments/agencies as outlined in Procedures for Providing Reasonable Accommodation, Requesting Accommodations, 3. Employees b. with Application Form. The departmental Accommodation Resource Manager shall inform the Public Works Department Administration Office of the employee's need for accessible parking and submit the completed Application form. I hereby apply for an assigned parking stall in the Hawai'i County Facility Parking as specified above. ❑Please check here if special needs are Applicant's Signature required, as per ADA. Explain: Date County Seniority Date Effective Date (Start Parking) --------------------------------------------------------------------- --------------------------------------------------------------------- ❑Current Driver License (expiration date) Primary Vehicle Information: Registered Owner License Plate No. Make Year Type Secondary Vehicle Information: Registered Owner License Plate No. Make Year Type ----------------------------------------------FOR PUBLIC WORKS INPUT----------------------------------------------- Parking Area Stall Number APPROVED: Public Works Authorized Signature Date County of Hawai'i is an Equal Opportunity Provider and Employer.