CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS
Police and Parking Services
CSUCI Permit
Number Issued
One University Drive Camarillo CA 93012
(805) 437-8430 (O) (805) 437-8431 (F)
PARKING REGISTRATION APPLICATION
For Faculty (Annual and Academic Year), Staff, Restricted and Tenants
Participants of carpools must submit their applications simultaneously and one vehicle owner must be identified as the party responsible for
paying the required fees.
PERMIT
Annual
CATEGORY
Faculty (Annual) Staff Tenant Restricted
(Requires Presidential Approval) Other
REGISTRANT INFORMATION
LAST NAME FIRST NAME ID # (Assigned by TPS)
IF TENANT, EMPLOYER NAME MAILING ADDRESS
CITY STATE ZIP CODE
HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER EMAIL ADDRESS
VEHICLE INFORMATION
(For owners of multiple vehicles, only one permit will be issued, unless the 2
nd
vehicle is a motorcycle)
VEHICLE #1 - ARE YOU THE REGISTERED OWNER OF THIS VEHICLE? Yes No If no, write name(s) below.
VEHICLE MAKE VEHICLE MODEL
REGISTERED OWNER NAME(S)
VEHICLE COLOR(S) LICENSE TAG NUMBER
STATE VEHICLE YEAR
VEHICLE #2 - ARE YOU THE REGISTERED OWNER OF THIS VEHICLE? Yes No If no, write name(s) below.
VEHICLE MAKE VEHICLE MODEL
REGISTERED OWNER NAME(S)
VEHICLE COLOR(S) LICENSE TAG NUMBER
STATE VEHICLE YEAR
VEHICLE #3/MOTORCYLE - ARE YOU THE REGISTERED OWNER OF THIS VEHICLE? Yes No If no, write name(s) below.
VEHICLE MAKE VEHICLE MODEL
REGISTERED OWNER NAME(S)
VEHICLE COLOR(S) LICENSE TAG NUMBER
STATE VEHICLE YEAR
PARKING FEES
Faculty Annual (Unit 3) Lots A1-A11, & D1 $27.49/month
Faculty Academic Year (Unit 3) Lots A1-A11, & D1 $196.90/year or $16.41/month deduction
Staff (Units 2, 5, 7, 9) Lots A1-A11, & D1 $26.89/month
Staff (Units 4, 6, 8) Lots A1-A11, & D1 $25.00/month
Staff (MPP, Non-Represented & Consultants) Lots A1-A11, & D1 $32.25/month
Tenants Lots A1-A11, & D1 $32.25/month
For staff and faculty, a “Notice to the State Controller of Payroll Deduction Authorization” form must be submitted with application.
Please make check or money order payable to: CSUCI
OFFICE USE ONLY
FORM OF PAYMENT
Cash Check # Money Order #
DATE RECEIVED AMOUNT RECEIVED
PAYROLL DEDUCTION AUTHORIZATION RECEIVED
Yes No
DATE RECEIVED MONTHLY DEDUCTION PAY PERIOD STARTING DATE
DATE PERMIT MAILED
DATE PERMIT PICKED UP
APPLICATION PROCESSED BY: _________________________________________________________________________
