Student/Staff Gated Access Authorization Form

Full Name

�ϰ��ϲʹٷ�� ID Number

Email Address

Phone Number

Copy/Photo of ADA Certificate of Registration

Please upload a copy or photo of the ADA Certificate of Registration.
One file only.
8 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

Disabled Placard Number

Copy/Photo of Disabled Placard

Please upload a copy or photo of your disabled placard.
One file only.
8 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

Disabled Placard Issuing State

Disabled Placard Expiration Date

Type of Permit Purchased

(Green, White, or Prospect)

Term/Semester Needed

Registrant Authorization

The undersigned hereby acknowledges and understands the rules and policies of �ϰ��ϲʹٷ�� Parking Services and that access to gated facilities is granted through your Viking Card. In addition, registrant understands they should park in disabled spaces with their disabled placard displayed and their license plate registered to a valid permit. You understand that permits are virtual and the vehicle’s license plate must be visible from the drive aisle.

�ϰ������ϲʹٷ�����

Student/Staff Gated Access Authorization Form

�ϰ��ϲʹٷ��