Author: Ismael Rodriguez

For Office Use Only
Permit Number
RFID # Lot #

1117 E Sixth St | Tucson, AZ 85721
(P) (520) 626-7275 | (F) (520) 621-7055

Carpool Permit Application

Point of Contact Name_______________________ University Affiliation_______________________________ Student/Employee ID#_____________________________ Telephone #_____________________________________ Email___________________________________________

Carpool lots Lot 1018 Lot 3039 Lot 4052 Lot 5072 Lot 6097 Garages-limited

Permit Request
1st choice _______________________
2nd choice ______________________

Name of Driver	License Plate	State	Year	Make	Model	Color
1.
2.
3.
4.

LOST OR STOLEN PERMITS ARE NOT REPLACED FREE OF CHARGE.

I also affirm that the information supplied on this form is complete and true. I understand that failure to comply with the requirements stated in The University of Arizona Motor Vehicle Parking and Traffic Regulations and Arizona Revised Statutes 49-542 and 15-1627G may result in the assessment of fees and fines, impoundment or other institutional enforcement and/or disciplinary action. I agree to follow the guidelines set forth by Parking and Transportation for the carpool program. Any abuse or deception by any member in the carpool program is grounds for surrendering the carpool permit and reserved space. Any type of falsification or improper use of a University of Arizona parking permit or persistent violations are grounds for citations, impoundment of vehicle, or revocation of parking privileges. RFID units--I understand that the radio frequency identification device (RFID) is the property of The University of Arizona Parking and Transportation Services (PTS). Should I discontinue my permit for any reason, I will return the RFID unit to PTS within 30 calendar days. Failure to do so will result in a currently approved non-return RFID fee. I hereby authorize PTS to charge the fee through payroll deduction or to my Bursar’s account (whichever is appropriate) at the time the RFID fee is due. If I don’t pay through this method, I will make payment directly to PTS. I understand that failure to pay this fee would result in collection action in accordance with the UA Motor Vehicle Parking and Traffic Regulations. This agreement is in effect until the device is properly returned to PTS. If you fail to pay on time and The University of Arizona Parking and Transportation Services Department refers your account(s) to a third party for collection, a collection fee of up to 33.3% or the maximum allowable by law, whichever is lower, will be assessed and will be due and owing at the time of the referral to the third party.
Signature (POC) ___________________________________________________________ Date ____________________

Received by	Date received	Notified	Location	Appointment date

For Office Use Only
Permit Number
RFID # Lot #

1117 E Sixth St | Tucson, AZ 85721
(P) (520) 626-7275 | (F) (520) 621-7055

Please complete the information below. Local addresses will be verified from UAccess.	FOR OFFICE USE ONLY
Carpooler 1 (Point of Contact)__________________________________ University Affiliation__________________________________________ Student/Employee ID#________________________________________ Telephone #________________________________________________ Email______________________________________________________	Account # Outstanding cites / Student # credits Employee FTE / Current Assignment Approved Y/N / Notes:
Carpooler 2 Name____________________________________________ University Affiliation__________________________________________ Student/Employee ID#________________________________________ Telephone #________________________________________________ Email______________________________________________________	Account # Outstanding cites / Student # credits Employee FTE / Current Assignment Approved Y/N / Notes:
Carpooler 3 Name____________________________________________ University Affiliation__________________________________________ Student/Employee ID#________________________________________ Telephone #________________________________________________ Email______________________________________________________	Account # Outstanding cites / Student # credits Employee FTE / Current Assignment Approved Y/N / Notes:
Carpooler 4 Name____________________________________________ University Affiliation__________________________________________ Student/Employee ID#________________________________________ Telephone #________________________________________________ Email______________________________________________________	Account # Outstanding cites / Student # credits Employee FTE / Current Assignment Approved Y/N / Notes:

Method of Payment
____Check or Money Order (payable to the University of Arizona)
____Credit Card (Visa, MC, AmEx)
Required for credit card payment: Signature___________________________ Print name as it appears on card_________________________________________
Card #___________________________ Exp Date_______ Zip Code______ Sec Code_____