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2. Instructions
   1. When you submit your form you will be redirected to make your payment on Square.
   2. After your information and payment have been verified we will mail your permit to you, please allow for 5 business days for shipping. 
4. First Name*
5. Last Name*
7. Mailing Address*
9. Address2
11. City*
12. State*
13. Zip*
15. Email Address*
19. Number of Vehicles Registering*

    You can register up to three (3) vehicles per affdavit. How many vehicles will you be purchasing Parking Permits for on this affidavit?

    1. 1
    2. 2
    3. 3
21. Vehicle Make and Model*

    Example: Honda Civic

22. Vehicle Year*
    Example: 2015
23. Registration Expiration Date*
    Registration Expiration Date
25. License Plate State and Number*

    Example: FL 876FTG

26. Vehicle Registration*

    Is this vehicle registration current?

    1. Yes
    2. No
28. 2. Vehicle Make and Model

    Example: Honda Civic

29. 2. Vehicle Year

    Example: 2015

30. 2. Registration Expiration Date
    2. Registration Expiration Date
32. 2. License Plate State and Number

    Example: FL 876FTG

33. 2. Vehicle Registration

    Is this vehicle registration current?

    1. Yes
    2. No
35. 3. Vehicle Make and Model

    Example: Honda Civic

36. 3. Vehicle Year

    Example: 2015

37. 3. Registration Date
    3. Registration Date
39. 3. License Plate State and Number

    Example: FL 876FTG

40. 3. Vehicle Registration

    Is the vehicle registration current?

    1. Yes
    2. No
42. Rates & Fees

    Resident Rate is $20 per calendar year. In order to receive the Resident rate, your address needs to be within city limits. The taxing district code 26H must appear on the property information online at the Brevard County Property Appraiser's office.

    Non-resident Rate is $75 per calendar year.

    A $3 Convenience Fee is included in your online payment 

44. Residency*

    Are you a Cocoa Beach Resident?

    1. Yes
    2. No
46. Cocoa Beach Address
50. Affidavit Statement*

    1. I hereby state that the information above is true, to the best of my knowledge. I also confirm that the information here is both accurate and complete, and relevant information has not been omitted.
52. Signature*
53. Date
    Date
57. Important Information
    Permit is valid for all metered parking areas except Shepard Park. Permit does not extend 90 minute parking limits. Vehicle is subject to citation if the decal is not properly attached.
59. Where to place your Parking Decal
    

    The parking decal must be affixed to the driver side rear bumper or the driver side lower rear window.
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit Submit and Print

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