University of Connecticut Avery Point Campus
Parking Decal Application

Special Instructions:

Complete all information below and bring to police building for decal.

Faculty/Staff Student Other

Date

(mm/dd/yyyy)

Name

Last, First

Address

Street

City, State, Zip Code

Telephone Information

Daytime Telephone (xxx) xxx-xxxx

Evening Telephone (xxx) xxx-xxxx

Vehicle Information:

eg, CT

Plate #

Make

Model

Year

Color

Employing Department

(Faculty/Staff ONLY)

With my signature on this form, I acknowledge that the motor vehicle registered herein, or any other motor vehicle under my control is subject to be ticketed, towed, or immobilized when the vehicle is found to be in violation of the University of Connecticut rules and regulations and that the decal/permit is for my personal use and may not be transferred.

Signature ___________________________________________Date:_____________________

University of Connecticut Avery Point Campus Parking Decal Application