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