Office Use Only: Property and Facilities Division Form Permit No. 30/10/14 Parking Permit Application Form PF01 For information on Parking @ UQ, permit terms & conditions, fees and charges, please visit: www.pf.uq.edu.au/parking/ 1. PERMIT TYPE - YOU MAY ONLY SELECT ONE PERMIT TYPE FROM THIS LIST Permit Type : Click on drop down arrow to select Permit Type * If you have selected Part-time or Special Need Parking Permit from the drop-down list above, please also select the days of the week you wish the permit to be valid. A part day is treated as a full day. Mon Tues Wed Thurs Fri Request for Special Consideration – please detail: 2. APPLICANT DETAILS (if insufficient address or vehicle details are supplied the form will be returned to applicant for completion) UQ Staff No. Student No. (UQ staff only, if applicable) (if applicable) Surname First Name Title UQ Org Unit/ Business Name UQ Building UQ Room No Postal Address Email Mobile Telephone Vehicle Reg. No. Make (e.g. Ford, Holden, Toyota) Permit commencement date / / Permit expiry date (only specify if purchasing a short-term permit) / / The University does not accept any responsibility for the (1) loss or damage to any vehicle; or (2) loss or damage to any article or thing, in or upon any vehicle or for any injury to any person, howsoever such loss, damage or injury may arise, including by way of negligence by the University. Signature of Applicant: ………………………………………… Date: / / 3. PAYMENT DETAILS - SELECT ONE PAYMENT TYPE (where applicable) PAYROLL DEDUCTION AUTHORITY - Complete this section if you wish to pay for permanent parking by regular deductions from your salary (only permanent UQ staff are eligible for salary deductions – this option is not available for casual staff or for the Gatton Undercover Car park) Staff No Surname Initials School/Section I authorise The University of Queensland to deduct from my salary the amount payable. The amount is to be deducted in regular fortnightly instalments. I agree that unless I return my parking permit before ceasing employment, The University of Queensland may deduct from monies owing to me (including salary or wages) the difference between the amount I would have paid for permanent parking if I had not had payments deducted from my salary and the sum of the deductions from my salary for the year in question. A part fortnight is charged as a full fortnight. Signature ………………………………………… Date: CASH * /CHEQUE/ MONEY ORDER/EFTPOS Please charge $ Initials: Card holder name: Please submit to PF Assist: / CREDIT CARD PAYMENT AUTHORITY Surname: Please do not send cash through the mail. *Cash payments are taken at Central Cashier, Lvl 3 JD Story Building #61. Please visit PF Assist, Prentice Bldg #42, to obtain permit number first. / towards my: Mastercard Visa Card Card No. Expiry Date: / Signature of Card holder: ………………………………… Date: / / Fax: (07) 336 51900; Email [email protected]; Phone: (07) 336 51016; Post or hand deliver: PF Assist, Property & Facilities Division, Level 2, Prentice Building (42), The University of Queensland 4072