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:___/___/_____


Collision Insurance:

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.


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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