KENTUCKY STATE UNIVERSITY PARKING DIVISION 400 East Main Street Frankfort, KY 40601 lephone: 502-597-5986 Fax: 502-597-5827
Lost, Stolen or Damaged Form
Date: _____
Date
Name ___
Name
KSU ID# ___
KSU ID
Address ___
Address
Include : City, State and Zip
Date lost, stolen or damaged: ___
Date lost, stolen or damaged
Old Decal# ___
Old Decal
Reason for Replacement:
___ ___ ___ ___ ___ ___
Signature:
I hearby certify that the above is a true and accurate statement.
DO NOT WRITE BELOW THIS LINE
New Permit #
___
Date Issued: ___
Replacement Fee:
$20.00 1st time replacement $40.00 2nd time replacement
$40.00 2nd time replacement
Surrender of damaged Permit | Yes | No
Yes
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Parking Officer Signature