Parking Permit Application Form
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12150 Kittredge Street
Parking Permit
First Floor
Berkeley, CA 94720-5740
Application Form
Tel: (510) 643-7701
Fax: (510) 642-9004
Applications must be submitted in person. We do not accept forms by fax or mail.
DATE:
P
/D
I
ERSONAL
EPARTMENTAL
NFORMATION
O
U
O
:
FFICE
SE
NLY
Name:
Customer Account No:
a L
t s
r i F
t s
MI
U
C
I
: D
Payroll Deduction Start Date:
Pa
r y
l o
T l
t i
e l
U (
C
S
a t
f f
o
n
y l
: )
T
t i
e l
C
o
d
: e
P
I
ERMIT
NFORMATION
Campus Dept:
Permit Type:
C
a
m
p
s u
A
d
r d
s e
: s
M
l i a
C
o
d
: e
Permit No:
Campus Phone:
Exp:
Home Address:
Type:
Street
C
y t i
S
a t
e t
Zip Code
Home Phone:
No:
E-mail Address:
Shuttle Card #:
Permit:
V
I
EHICLE
NFORMATION
$
Annual transportation Fee:
Vehicle 1
$
Total Amount Paid:
license plate no.
state
year
make
model
$
Vehicle 2
Notes:
license plate no.
state
year
make
model
Motorcycle/Moped
Processed by:
license plate no.
state
year
make
model
P
M
AYMENT
ETHOD
OPTION 1:
Start monthly payroll deduction (Faculty/Sta only)
I authorize $___________ to be deducted each month from my paycheck.X ________________________________________________
signature of applicant
OPTION 2:
Pay annual fees in full -
Accepted form of Payment (in person only)
Cash )
Check # ________ (payable to UC Regents)
Credit Card:
Visa
MasterCard
Discover
I understand that parking permits are subject to revocation if incorrect information is given or if published rules are violated. I understand
that the parking permit issued to me does not guarantee me a parking space. I understand that I am responsible for this permit as long as it
is in my possession. There is a $35.00 replacement fee due if permit is lost or discarded. Alteration, Duplication, Misuse, Transfer or Resale
of this permit is prohibited.
X_______________________________________________________
__________________________________________________
s
g i
a n
u t
e r
f o
p a
i l p
a c
t n
a d
e t
WF 060017 0706
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Parent category: Business