EmailMe Form - Temporary Permit Registration

Name: *

First Last

Date of Birth *

LMU ID Number: *

Email *

Existing Permit Number: *

Temporary Permit Request Explanation *

License Plate Number: *

Vehicle Make: *

Model: *

Color: *

Year: *

Vehicle Registered to: *

First Last

Registrant's Phone Number: *

### - ### - ####

Signature: *

Clear

By signing/checking below, I certify that the above information is correct, that I understand the Temporary permit is valid for a time to be determined by Campus Police & Security, but no longer than one month from the date of issuance, and that if I use the Temporary Permit outside of its intended purpose, it can be considered a fraudulent permit action and I may be cited as such.