Citation Payment Plan

First Name * Last Name * Student/Staff ID # (If Applicable) License Plate # * Balance Owing * Citation Number(s) * Phone Number *

Voicemail Yes No

Email Address *

Please Select Payment Schedule For Citation Payment Plan: * Monthly Payments (due the by the 1st of every month) Bi-Weekly Payments

By applying for a Citation Payment Plan, it is considered an admission of guilt in relation to the included citation(s). Your application submission will hereby waive the right to further appeal these citations through the University of Regina or Provincial Bylaw Court. Do you accept the terms of application? * Yes No

Have you previously defaulted on a Citation Payment Plan with Parking Services? * Yes No

You have reviewed and accept the Terms and Conditions of a Citation Payment Plan. * Yes No

Reason for Application *