RETURNED PERMIT FORM
Name: / UTEP ID #:
Address: / UTEP Email:
City: / State: / Zip Code: / Phone #:
Select one of the following:
Upgrade to / (indicate permit type)Customer is responsible to pay difference in cost for upgraded permit.
Downgrade to / (indicate permit type)
Traffic office to post credit on customer’s BANNER/Goldmine Account
Return for refund. / Refund may be based upon a pro-rated amount. (indicate reason for return)
Signature: / Date:
FOR TRAFFIC OFFICE USE ONLY
Original Permit Number: / Amt. Paid / Amt. Due
UPGRADE
$ / Current price of new permit
( ) / Less pro-rated refund of original permit or amount paid towards original permit
Sub-total
5.00 / Administrative Fee(if applicable)
6.00 / Upgrade Fee
$ / Amount to be charged to BANNER/Goldmine
DOWNGRADE
Current price of permit
( ) / Less prorated refund of original permit price or amount paid towards permit
( ) / Sub-total
5.00 / Administrative Fee(if applicable)
($ ) / Amount to be credited to BANNER/Goldmine
RETURNED FOR REFUND
( $ ) / Current price of permit or amount paid towards permit
5.00 / Charge of administrative fee (if applicable)
($ ) / Amount to be credited in BANNER/Goldmine
New permit number issued: / RFID #: / (if applicable)
Processed by: / Date:
Examples:
UPGRADE$ 327.21 / Current price of new permit
( 116.86 ) / Less pro-rated refund of original permit or amount paid towards original permit
$ 210.35 / Sub-total
5.00 / Administrative Fee (if applicable)
6.00 / Upgrade Fee
$ 221.35 / Amount to be charged to BANNER/Goldmine
DOWNGRADE
$ 93.49 / Current price of permit
( 116.86 ) / Less prorated refund of original permit price or amount paid towards permit
( 23.37 ) / Sub-total
5.00 / Administrative Fee (if applicable)
($ 18.37 ) / Amount to be credited to BANNER/Goldmine
RETURNED FOR REFUND
($116.86 ) / Current price of permit or amount paid towards permit
5.00 / Charge of administrative fee (if applicable)
($111.86 ) / Amount to be credited in BANNER/Goldmine
Note: If the permit is returned unopened or unused, the $5.00 administrative fee is waived.
Revised 09/25/07