Date:    Banner ID:

Last Name:   

First Name:

Address:    -
                    Street or Box/City/State/Zip
Phone: -

Permit #

General Parking Only: Yes   No    

Priority Parking Requested: Yes   No    Lot #:

All Day Evening Only (After 4:30 PM)

Are you currently registered student with U of M Yes No

RESIDENT PARKING - I am a U of M student living on campus. I understand that falsification, misrepresentation, and/or distortion of any information on this form is a violation of the student code of conduct.

Resident Hall Live in Requested Lot #:    

Campus Resident Signature ____________________________________________________________

See map for lot Information.

Cash Check Credit Card      Amount Paid $ _________________

Win DSX        ________________________________________       Date _________________

Power Park   ________________________________________       Date _________________