Accessible Parking Request Form
Office of the Assistant to the President for Institutional Diversity and Equity
UNIVERSITY DISABILITY SERVICES
Name: *
Your answer
Phone: *
Your answer
Email: *
Your answer
Affiliation
Functional Limitations
Building Name/Address: *
Your answer
Date of Visit: *
MM
/
DD
/
YYYY
Arrival Time: *
Time
:
Name of individual Driving *
Your answer
Vehicle Color/Make/Model *
Your answer
License Plate Number and State:
Your answer
Accessible Parking Space Type:
Do you have a state-issued disability parking permit or plate?
If yes, what is the expiration date and placard number?
Your answer
I submit this request. My typed name serves as my digital signature: *
Your answer
Submit
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