State Employee Parking Request

BEACON #
/ Last Name:
/ First Name:
/ MI
Department Code:
D / Department:
/ Division:
Transaction Type:
New Assignment
Transfer
Termination / New/Current Assignment: / Transfer Assignment: / Effective Date:
Lot #:
/ Lot #:
Space or Permit #:
/ Space or Permit#:
/ Transponder/Gate Card #:
Home Address
Mailing Address:
/ City:
/ State:
/ Zip+4:
Work Address
MSC #:
/ City:
/ State:
/ Zip+4:
Building Name: / Work Phone: / Email:
Vehicle Information
Vehicle 1 / Plate #: / State: / Make: / Model: / Color:
Vehicle 2 / Plate #: / State: / Make: / Model: / Color:
Vehicle 3 / Plate #: / State: / Make: / Model: / Color:
Payment Information
Payment Type:
Payroll Deduction
Check/Cash
Credit/Debit Card / Employee Payroll:
Monthly
Biweekly
Not on Beacon Payroll / Monthly Parking Fee:
$
Individuals who cannot be payroll deducted must pay annually through June 30. / Any initial fee must accompany application.
Initial Fee Due: (if applicable) $
Cash/Personal Check
Credit/Debit Card(Card must be swiped at State Parking Office.)
By accepting a parking assignment, the employee agrees to the following:
  1. Payroll deductions for my parking assignment will be made and credited to my parking account.
  2. Payroll deductions may be adjusted for space and fee changes.
  3. I will be responsible for all fees associated with my parking assignment until State Parking is notified in writing to terminate my parking assignment.
  4. If my assignment is in the B3 Zone, I understand I am not entitled to parking relocation should this zone become unavailable.
  5. I will abide by the parking rules and regulations of the State Parking Division.
______
Employee’s Signature Date Parking Coordinator’s Signature Date
Application not validwithout signatures.

Parking assignment/changes are not valid until this form is received and processed by the State Parking Division. Use this form for both assigned space and zone parking assignment requests.

DOA-SBD-PP-115 REV. 11/10