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2. 
3. ROLL OUT SERVICES APPLICATION

   
   

   To apply, please fill out this application and upload supporting documents. If approved, you will receive a letter from the Finance Department and the service will become effective within sixty (60) days after the date of approval. If denied, you will receive a letter stating the reason for the disapproval. If you have any questions, please contact Maggie Poon at mpoon@montereypark.ca.gov or call  (626) 307-1338.

5. FULL NAME OF APPLICANT
7. SERVICE ADDRESS
8. UTILITY ACCOUNT NO.
10. EMAIL ADDRESS
11. PHONE NO.
13. DMV PLACARD NO. OR PHYSICIAN'S NAME*
14. ATTACH DOCUMENTS
16. NOTE

    * If using a doctor's note, please attach a recent certification signed by your physician

20. SIGNATURE AND ACKNOWLEDGEMENT

    I understand that I am required to renew my certification annually and notify the City of any change in information to maintain my eligibility. Failure to do so may result in my removal from this program. I agree that by completing this form and submitting it to the City in an electronic format, such as email, it will have the same legal effect as a form submitted by U.S. Mail or in-person. I certify, under penalty of perjury under the laws of the state of California, that the information I have provided in this application is true and correct.

22. PRINT NAME
23. SIGNATURE
25. DATE
29. FOR OFFICE USE ONLY

    1. NEW APPLICATION
    2. RENEWAL
30. RECEIVED BY
31. DATE RECEIVED
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field