Employee Parking Application - Oregon Department Of Administrative Services
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1
2Fleet & Parking Services
1100 Airport Rd SE
Employee Parking Application
Salem, OR 97301-6082
503-378-5090
503-378-2157 fax
state.parking@oregon.gov
Name:
Employee ID#:
(Non-state employees, enter last 4 digits of SS #)
Last
First
MI
Agency Name:
Agency Number:
Division/Section:
Worksite Address:
Street/City/Zip
Work Phone:
Email:
For events & issues relative to your parking assignment
YOUR VEHICLE DESCRIPTIONS
Vehicle #1 – Year/Make/Model:
State:
Plate:
Vehicle #2 – Year/Make/Model:
State:
Plate:
Vehicle #3 – Year/Make/Model:
State:
Plate:
Pre-tax payroll deduction authorization
I hereby authorize my employer to deduct from my salary or wages due me by virtue of my employment with the State of
Oregon, all sums owed to the Department of Administrative Services for the parking privileges I have been assigned. I
understand that the parking charge may increase or decrease. This request and authorization shall remain in force
until canceled by me in writing/email and any parking permit or sticker is returned to the Department of
Administrative Services, State Parking. Parking payroll deductions are made in arrears and are pre-tax unless a waiver
is submitted to the agency payroll office.
Cash payment (non-state/temporary employees only – requires pre-approval of Parking Manager)
I elect to pay for parking in advance by cash each month. I understand that if the payment is not received in the Parking
Office by the fifth calendar day of the month, my parking privileges will be canceled.
I understand that parking regulated by the Department of Administrative Services is subject to the provisions of OAR Chapter
125, and ORS Chapters 98, 276, 283, and 292. By accepting a parking assignment made by the Department, I agree to abide
by these rules and laws. I further understand that failure to abide by these rules and laws may result in citation, prosecution
and/or loss of parking privileges.
Signature
Date
OFFICE USE ONLY
Lot Assigned, Space/Permit Number_____________________________________ Monthly Rate_________________
Effective Date________________________________________________ Payroll Notification___________________
U:\PKG\Forms\EmployeeApplication.docx
Updated 8/25/2017 ICD
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