CSU – CAL MARITIME
PARKING PERMIT PAYROLL DEDUCTION AUTHORIZATION &
EMPLOYEE PARKING PERMIT APPLICATION
PARKING PERMIT PAYROLL DEDUCTION AUTHORIZATION (To be completed by Human Resources)
Name: Department:
Bargaining Unit: (Select One) 1 2 3 4 5 7 8 9 10 C99 M80
Units 2, 5, 7, 9: 10/12, Academic Year, or Cruise ($11 per month) 12-month ($14 per month)
Units 1, 4, 8, C99, M80: 10/12 or Cruise ($15 per month) 12-month ($18 per month)
Unit 3: Academic Year ($9 per month) 12-month ($12 per month)
Unit 10: 12-month ($16 per month)
HR Authorization: Date:
EMPLOYEE PARKING PERMIT APPLICATION (To Be Completed by Employee; Typed Forms are Preferred)
Name:
Last
First
MI
Permanent
Address:_
City
ST
Zip
Telephone:
Cell
#:
Alternate
#:
Vehicle 1:_ /
/ / /
Year Make and Model Color License Plate # State
Vehicle
1:
Registered
Owner’s
Name
:_
Vehicle 2:_ /
/ / /
Year Make and Model Color License Plate # State
Vehicle
2:
Registered
Owner’s
Name
:_
IMPORTANT – Please Read.
I, the undersigned, have read and understand the CSUM Parking Rules and Regulations posted on www.csum.edu. I understand that illegally
parked vehicles may be cited, immobilized or towed at my expense. The permit issued to me is non-transferable to any other individual. I
understand that the California Vehicle Code, Vallejo Municipal Code and the CSUM Parking Rules and Regulations are enforced at all times. I
certify that the vehicle registration is in my name or in the name of an individual within my household.
By signing this form, you acknowledge that you have read and understand the above statements, and that all information you have
provided on this form is accurate and true.
Signature:
Date:
FOR UPDATES TO YOUR VEHICLE RECORDS, please contact Police Services: 707-654-1179
IN CASE OF AN EMERGENCY INVOLVING YOUR VEHICLE(S), please provide and emergency contact:
Primary
Emergency
Contact
Name:
Phone:
Alternate
Emergency
Contact
Name:
Phone:
To be completed by the Cashier:
Permit
Number: _
Date
Issued:
Cashier:
Rev.2016-0628
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signature
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