Vehicle Registration-Parking Permit

This form must be completed and the parking sticker recieved in order to park on the XXX Campus.

Full Name

First NameLast Name

Are you a(n)

StudentEmployee

Student ID Number

Permit Number

Phone Number

E-mail

example@example.com

Department

Class Status:

FreshmanSophomoreJuniorSenior

Do you live:

On CampusOff Campus

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

On Campus Building

Apartment Number

CCU Mailbox # (if known)

Vehicle #1

Make of Vehicle #1:

Model of Vehicle #1:

Primary Color of Vehicle #1

Year of Vehicle #1:

Plate Number of Vehicle #1:

Vehicle # 1 State registered

Insurance Company:

Vehicle #2

Make of Vehicle #2:

Model of Vehicle #2:

Primary Color of Vehicle #2

Year of Vehicle #2:

Plate Number of Vehicle #2:

Vehicle # 2 State registered

Come to the XXX Building during WOW at the Event Center to pick up your parking permit. If you do not get your permit during WOW, please come to the Security Office to pick it up.

I, undersigned, agree with the following statements:

I affirm that my vehicle is in compliance with XXX State Law.I have read and understood the campus rules and understand that if I do not follow the rules, my permit will be revoked.

Date

Signature