Request For Transportation Form

Request For Transportation Form
Phone: 2-6397 FAX: 2-6395

Note: All drivers of large vans must have University Van Operator Training Course Map

There is a $75.00 charge for lost key/credit cards | State employees ONLY are allowed to drive | Vehicles are to be used for official business only.

Name Of Driver:	Employee ID# (Woo Number)	No. of Travelers:
Date:	Driver's Work Phone:	Driver's Home Phone:	Type of Vehicle:

AUTHORIZATION AND STATEMENT OF LIABILITY: I, as Dept. Head or Authorized person for the Dept. agree to accept the responsibility for all charges, including vehicle damage caused by abuse, which are incurred during the time the vehicle is checked out for department use.
Department Head Signature:________________________________________ Date:___/___/_____

Facilities Job No.:

Customer No.:

Account No.:

Department:

Requisition #:

Pickup Date:

Time:

Return Date:

Time:

Collision Insurance:

Dept. will pay $2.26 Collision insurance premium Do not desire to pay collision insurance

Destination and Purpose:

DRIVER'S CERTIFICATION: For my protection and the protection of my department, I agree to inspect the vehicle assigned to me BEFORE I leave the parking lot. If I notice any damage or problem with the vehicle, I will have a Motor Pool employee make a note of the damage BEFORE leaving the lot and retain a copy for my department. I agree to remove all debris from inside the vehicle. I certify that I have the valid driver's license listed below.

Driver's License #: State: Expiration Date:

Drivers Signature:______________________________

DO NOT WRITE BELOW THIS LINE! TO BE COMPLETED BY THE MOTOR POOL

Departure Date: _____/_____/_______	Departing Time:	a.m. p.m.
Returning Date: _____/_____/_______	Returning Time:	a.m. p.m.
Total Days_______


Mileage	Amount of Charges
Odometer Reading
Finish:
Start:
Total Miles
Minimum Charge:
Per Mile x
Total Mileage Charge
Insurance Premium Charge
Other Charges
TOTAL CHARGES

Vehicle Number: ___________________

Comments:_______________________________________________________

Instructions for Printing this Form See details of charge list

Please note that you MUST call and reserve the vehicle first.

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