(PLEASE PRINT)

Parking Lot________________________  Permit No_______________________  Expiration Date____________________________

DO NOT WRITE ABOVE THE LINE

NAME__________________________________________________________________________
           Last                               First                                 M.I.

Employee ID No.______________________ (Student ID)_________________________

Local Address_____________________________________________

City:__________________ State_________________         Zip____________

Campus Dept: Office-School or College________________________ Room No.______

Office Phone: _________________Home Phone:___________________

E-mail:____________________________________________________

Make of Primary Vehicle_____________________ Year__________ Color__________

Primary License Plate No.__________________ State___________

Make of Secondary Vehicle___________________ Year___________ Color________

Secondary License Plate No.________________ State____________

Faculty  ______             Staff   ______           Student  _____       

Name of Registered Owner of Vehicle___________________________

I agree to abide by all of Howard University's Parking Regulations, and the information given is true to the best of my knowledge.

Signature______________________  Date_______________