University of Mississippi
Department of Parking and Transportation
120 Lester Hall
University, MS 38677
Bicycle Registration Form
Starting July 1st, 2015, bicycle permits are free and valid for four years from the date issued. To receive a permit, bring the completed form
to the Ole Miss Bike Shop located across the street from the Turner Center or to Rm 120 Lester Hall to receive permit.
Registration Information (all fields are required)
Contact Info:
Last ________________________ Middle _____________________ First____________________
Student/Staff ID___________________________ (put VISITOR if not active student/staff)
Email Address ____________________________
Local Address: (Permits will still need to be picked up from the Ole Miss Bike Shop or DPT's Office. 120 Lester Hall)
House/Appt. Number_____________________
Street _________________________________
City ________________________ State ________________________ ZipCode__________________
Basic Bicycle Information – (The information collected below will be entered into the same system
that issues automobile permits on the University campus, therefore the first section will follow the
same format) ( these fields are required)
Year _____________________ (a general year – guess if needed)
Other
Make _____________________
(Choose 'other' if not on the list and describe in final section)
Other
Model _____________________ (basic style of the bike – add decription in final section if needed)
Red
Color 1 ____________________
(Main body primary color - if not listed choose something similar)
Blue
Color 2 ____________________
(Main body secondary Color - can be the same as the primary color)
Serial Number ______________________________
Other Information (optional):
Estimated Value ________________
Common places
to find a bicycle
serial number.
Medium (17"-21")
Body Size __________________________________
Male
Body Style _____________________
Detailed Make-Model or Other Info (describe as needed)
Your request and acceptance of a permit for this bicycle is considered affirmation of your understanding and agreement of the
rules and regulations related to the operatiion of bicycles on the University campus. Bring the completed form to the Ole Miss Bike
Shop or DPT's main office located in Lester Hall Room 120. DPT staff will issue a bicycle permit at that time.
Bicycle Owner Signature: ___________________________
Date: _______________________
_______________________________________________________________________________________________
OFFICE USE ONLY
Decal Issued (Date) ________________________ Decal Number _____________________________
Issued by:______________ Notes________________________________________________________
___________________________________________________________________________________
Form: UM-Bike-Registration-Form-2016.pdf July 1st, 2015 - UM Dept. of Parking and Transportation