C&PS: Student Ticket Payment Form

Cornell University:
Transportation and Mail Services: Commuter and Parking Services

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Bursar Charge Authorization for Parking Violation Fines

This form is for registered Cornell students only.

By filling out this form you are requesting that Commuter and Parking Services send your parking fine(s) to the Bursar. We will record your fine as paid and you will be billed by the Bursar for the charges. Extramural students cannot use this form and can call (607) 255-PARK to pay by credit card.

Please fill in all fields of this form or we will be unable to process it.

Information About You:

Your Name:

Phone:

Student ID# :

NetID:

Information About Your Car:

License Plate Number:

State/Province:

Ticket and Payment Information

Please list seperately all tickets you would like us to forward to the bursar for payment. We send all charges to the bursar once a month on the day before bursar bills are generated. Your payment will not show up online immediately.
Please include the late fee for each ticket you are paying beyond 21 calendar days after the ticket was issued. Each ticket must be paid in full.

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

Ticket Number

	Amount:
	$

TOTAL AMOUNT: $

Signature:

By checking the "agree" box, I am signing this form. My signature certifies that all statements on this form are correct. All of this information is true and accurate to the best of my knowledge.

Agree

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