|
MOTOR
VEHICLE REGISTRATION
Name:
______________________________________________________________________________
Last
First
Middle
Campus Address:
_______________________________________________________________
Residence
Hall
Room Number
Home Address:
__________________________________________________________________
Number
Street
City
State
Campus Phone: _________________________ Cell
Phone:________________________
Emergency Use Only
p
Faculty-Staff
Student: p Resident
p Commuter
If student, check class:
p Freshman p Sophomore p Junior p Senior
License Plate Number:
_________________________ State: ______
Registered to:
___________________________________________
Description of Automobile:
Make:________
Model: ________ Year: ______ Color: __________
I certify that I am responsible for the accuracy of all
information contained herein. I am familiar with the regulations regarding the
operation and parking of motor vehicles on the campus and I agree to abide
by these regulations.
______________________ ___________________________________________________
Date
Signature of Applicant
*******************************************************************************************************
Internal Use Only
DREC:
_________________
RL SS
2ND NC
ENTERED: _____________
BILLED: _______________
|
