2. 
4. Residential Permit Parking District Application
6. HOA President or HOA Manager's Name*
   This person is the contact for the community and will receive correspondence from DTCI.
7. Title*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Preferred Contact Phone Number*
18. Work *
19. Cell *
21. Preferred Contact Email*
22. Work Email*
24. Type of Application*

    1. Near a High School/College Campus (Section 4(a))
    2. Metrorail Station
    3. Other (Section 4(b))
26. Boundaries of District
28. North*
29. South*
31. East*
32. West*
34. Approximate Number of Homes in Proposed District*
36. Approximate Number of Vehicles that will need a Permit By Type
38. Auto/SUV/Pickup*
39. Motorcycle*
41. Hours of the Day when Non-Resident Vehicles Park in the Proposed District
43. From / To*
    From / To Start Time

    —

    From / To End Time
45. Notes
47. I understand that Loudoun County and the Virginia Department of Transportation (VDOT) are under no obligation to establish parking restrictions that are not in concert with the Manuel on Uniform Traffic Control Devices, VDOT regulations or standards, Loudoun County policies and ordinances or that may pose a hazard to the public. I agree to provide any additional information and to provide coordination with the petitioning citizens and other within the proposed District as required by the County.
49. Applicant Name or Coordinator*
50. Date*
    Date
52. Signature
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field