Request For Parking Privileges – DAILY PAY

1 Revised: 30april2014/er Request For Parking Privileges DAILY PAY Applicant s Personal Information: ** ALL FIELDS REQUIRED. INCOMPLETE FORMS WILL NOT BE PROCESSED** Title (circle one): DR. MR. MRS. MISS MS. INPUT SITE: (see reverse page) LAST NAME: FIRST NAME: Employer / Affiliation: PHC PHSA VCH FHA Employee ID # or PHY Billing #: Dept.: Work Phone #: Ext.: Mobile/Pager/Home Phone #: Work Email: Personal Email: Office Address: (Street) (City) (Postal Code) Home Address.

2 (Street) (City) (Postal Code) Applicant s Vehicle Information: The registered passholder may park only one (1) vehicle at any one time. MAKE OF VEHICLE: MAKE OF VEHICLE: Licence Plate Number 1: Licence Plate Number 2: CRITERIA Applicant Must Meet Requirements Applicant must be: actively working for FHA, PHC, PHSA and/or VCH as follows: o PHYSICIAN with medical affairs/administration (must have active hospital Privileges and provide medical services) o EMPLOYEE as a health authority staff o CONTRACTOR EMPLOYEE as an employee of a service provider assigned at any PHC, PHSA and VCH facility/facilities Important.

3 Pass is valid at any unattended FHA, PHC, PHSA and VCH pay by stall Parking lots Pass must be CANCELLED & RETURNED upon termination of employment from PHC, PHSA and VCH FHA employees must apply for a DAILY Pay Hanger through the FHA Parking Administration Office FEES (SUBJECT TO CHANGE) $ Refundable Advance Deposit Provide payment as per PAYMENT OPTIONS on reverse page. Payment of refundable deposit is required prior to pass issuance Passes returned without a CANCELLATION FORM forfeit the refundable deposit $ Non-Refundable Replacement Fee (Replacement Application Form to be completed & submitted)

4 Payment required only when lost/stolen Parking pass needs replacement Fee is per occurrence Returned damaged valid pass will be replaced at no charge DAILY Staff Parking Rates Displaying the DAILY Pay Hanger entitles the user to select the DAILY staff rate option from the Parking meter at pay by stall facilities DAILY staff Parking rates varying from site to site & are subject to change at any time DAILY staff rate is payable at a meter via credit card or exact coin I confirm that all information provided on this form is accurate and that I have read, understood, and will abide by the Terms and Conditions (see reverse page) associated with the Parking pass.

5 Applicant s Signature: Date: Employment Status / Affiliation: Reg Full Time Reg Part Time Physician Temp FT/PT Casual Contract Staff Parking ADMINISTRATION OFFICE USE ONLY: Pass #: Deposit Mode: Deposit Amount: Date Issued: Issued by: $ Revised: 30april2014/er TERMS AND CONDITIONS (SUBJECT TO CHANGE) (APPLICANT TO KEEP TERMS & CONDITIONS PAGE) Parking SITES (With a booth attendant) Show your hospital Photo ID at attended hospital lots to avail of DAILY staff rate.

6 FHA FACILITIES (pay by meter stalls) - Burnaby - Chilliwack - Eagleridge - Langley - Peace Arch - JP Outpatient - Royal Columbian - Ridge Meadows - Surrey Memorial PHC FACILITIES - SPH (Level 1 and 2 Green Zone only) VCH FACILITIES - LGH Parkade (2 & 3) - Minoru Residences Exterior Lot (pre-qualified w/TRH sticker) - Richmond hospital Parkade PHSA FACILITIES - BCC & W (non-patient stalls only) RESTRICTIONS Passholder CANNOT assign or transfer this agreement without the prior written consent of Parking Administration, which consent may not be unreasonably withheld Passholder is limited to one [1]

7 Parking pass Passholder is responsible for remembering to display Parking hanger in vehicle while parked at any hospital site and selecting the DAILY staff rate CHARGES Parking meter fee is for the use of one Parking stall per payment User has in and out Privileges by displaying a valid meter receipt on dash of vehicle If the DAILY Pay Hanger is not clearly displayed, the Passholder must pay the public DAILY rate at the meter CONDITIONS Parking pass does not guarantee reserved Parking Parking Administration reserves the right at any time to refuse Parking at the Passholder s primary location Parking Administration will endeavor to relocate the Passholder to another available location for the period that the Passholder s primary location is unavailable Passholder is subject to the Terms and Conditions displayed on all signs in the Parking facility Parking Administration

8 Conducts random audits to uphold the integrity of the Parking program Parking Administration is not responsible or liable for any injury, death, property damage, theft or disappearance occurring in, on or about the Parking facility to the Passholder or anyone claiming under or through the Passholder ISSUANCE OF VIOLATION TICKET and/or TOWING OF VEHICLE AT OWNER S EXPENSE Unauthorized transfer of Parking pass is prohibited Vehicles not displaying a valid Parking pass will be issued an irrevocable Parking violation Vehicles impeding pedestrian walkways, doorways, fire lanes.

9 Emergency lanes or any other access ways may be towed at owners expense Noncompliance of Parking Terms and Conditions may result in revoking Parking Privileges CHANGES, CANCELLATIONS AND REFUNDS To cancel Parking , Passholder is required to notify Parking Administration in writing by requesting & submitting a Cancellation Form and returning Parking pass with Cancellation Form to Parking Administration office Refund of deposit, if any, will be processed accordingly upon return of Parking pass APPLICATION PROCESS PAYMENT OPTIONS 1) Complete the form ELECTRONICALLY and print to sign 2) Fax or email form to Parking Administration via: Fax: (604) 875-3269 Email: Mail Application Form w/ cheque payment: Parking ADMINISTRATION c/o bc children s hospital & Women s Health Centre Shaughnessy Bldg.

10 Room AB 100 4500 Oak St. Vancouver, BC V6H 3N1 3) Ensure that your contact information is accurate and complete. Parking Administration may need to communicate with you. 4) Upon receipt of the completed and signed application form AND payment, a Parking pass will be issued as follows: DAILY Pay seven [7] days (via mail) Immediately if picked up in personal (bring completed application form with you. PHC Parking Facilities (SPH) Credit card (Mastercard, Visa and American Express) Debit card/INTERAC (IN PERSON) You may call 604-875-4832 if paying via credit card.