Request for Transportation Form
Phone 532-6397 FAX 532-6395

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

Name Of Driver:

Employee ID# (Woo Number)

No. of Travelers:

Date:

Driver's Work Phone:

Driver's Home Phone:

Type of Vehicle: Sedan Trailblazer Pick Up Truck Minivan Cargo Van Van (8 Passenger) Van (12 Passenger) Van (15 Passenger) Suburban Bus

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

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

Mileage		Total Mileage Charge:
Odometer Reading Finish:	Minimum Charges:	Insurance Premium Charge:
Odometer Reading Start:	Per Mile x:	Other Charges
Total Miles:		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.