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Penn State Fayette

Parking Permit Application

This section to be filled out by Authorized Personnel

Semester:Fall: #__________Spring: #__________Summer: #________ Year:__________

Please complete this form, take the form to Police / Security Department, Room 121 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:____________