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.
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 and the driver is a State of Kansas employee.

Department Head Signature:________________________________________ Date:_____/_____/_____

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 and that I am a State of Kansas employee.
Driver's Signature:_____________________________________________________

Return to forms         Instructions for Printing Form         See detail list of charges

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

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 :
Odometer Finish : ____________________           Minimum Charge : _____________________
Odometer Start : _____________________      OR      Per Mile X = ________________________
TOTAL MILES ____________________
Expenses :
               Mileage Charge : ________________________________________
Insurance Premium : ________________________________________
Airport Charge : ________________________________________
Other Charges: ________________________________________ TOTAL CHARGES DUE ____________________

Vehicle Number : ____________________ Requisition # : _____________________ Comments : _____________________________________________