DEPARTMENT OF GENERAL SERVICES POLICE
DEPARTMENT OF GENERAL SERVICES POLICE
BALTIMORE STATE OFFICE CENTER
PARKING FACILITY PROX ACCESS
Car Pool Permits
Alternate Driver Advanced Notice Request Form
The purpose of this form is to allow an established Alternate Driver access to A, E, F lots and 201 Building garage when the Primary Driver is out 5 or more consecutive days. The PROX System will allow reports to be produced and reviewed to ensure proper use. Seventy-two hours advance notice is required.
PARKING PROX ACCESS: □ A Lot □ E Lot □ F Lot □ 201 Building
Beginning date: Until Close of Business date:
SUSPEND:
Primary
Driver’s Name: Date of Birth:
(Print) LAST FIRST MI
MDH/Agency: Last four numbers of Social Security Number
Office Address: Office Phone #
Front Card Number: Back Card Number:
ACTIVATE:
Alternate
Driver’s Name: Date of Birth:
(Print) LAST FIRST MI
MDH/Agency: Last four numbers of Social Security Number
Office Address: Office Phone #
Front Card Number: Back Card Number:
Authorization
Central Services Signature: Date:
Print Name:
13 September 2006
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