KSUS Motorpool Transportation Request Form

Request for Transportation
Today's Date*

MonthDayYear
Date
Name of Driver*

First NameLast Name
Driver's E-mail*
Driver's Work Number*

Area CodePhone Number
Driver's Cell Phone*

Area CodePhone Number
Pickup Date/ Time*

MonthDayYearHourMinutesAM/PM Option
Return Date/Time*

MonthDayYearHourMinutesAM/PM Option
Type of Vehicle (Choose only one)*

Sedan ($0.40/mile)MiniVan (7 passenger- $0.47/mile)Van (12 passenger- $0.50/mile)Pickup 4x4 - Trailer Hitch ($0.52/mile)
Number of Travelers*
Collision Insurance $2.33 per day (Mandatory)

This will prevent the department from paying for damages.
Destination*
Purpose*
Customer/Department No.*
Dept's Accountant E-mail*
Department Approver*

First NameLast Name
Dept. Approval Email*
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 damage or problems 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 a valid driver's license.
Agree to the terms of the Driver's Certification*

YesNo
All requests must be approved by your supervisor before vehicle is reserved. Please submit a form for each vehicle requested.
- - - - - - REVIEWING SUPERVISOR ONLY - - - - - -

This section will be forwarded to the Approver
Authorization and Statement of Liability

I, as Department Authorized person, 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 Authorized Name

First NameLast Name
Approval:

YesNo
Approval Date:

MonthDayYear
Should be Empty:

Request for Transportation

Driver's Certification

- - - - - - REVIEWING SUPERVISOR ONLY - - - - - -

Authorization and Statement of Liability