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PLEASE PRINT AND FILL OUT ALL APPLICABLE FIELDS

Once the form has been completed, take the form to the Office of Finance and Business Services, Room 106 Williams Building to receive your parking pass. All fields are required.

Name (Last, First, MI):_____________________________________________________

Cell Phone Number:__________________ Penn State ID Number:___________________

Local Address:____________________________________________________________

City:____________________________ State:__________ Zip Code:_________________

Check the appropriate box:

_____ Student    _____ Faculty

_____ Staff         _____ Part-Time Faculty or Staff

_____ Information Change

Vehicle Identification

Make of Vehicle:_______________ Model:______________ Color:___________

Year:________ License Plate Number:_________________ State:___________

Make of Vehicle:_______________ Model:______________ Color:___________

Year:________ License Plate Number:_________________ State:___________

I certify that I have read the regulations and agree to fully abide by them.

Signature:__________________________________________ Date:____________