Request For Transportation Form
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1Submit by Email
to: (pgrater@ksu.edu)
*must be saved locally before
Request for Transportation Form
submitting*
Phone: 2-6397 FAX: 2-6395
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:_________________________
K-State eID:____________________@ksu.edu
No. of Travelers:________________________
Driver’s Work Phone:____________________
Driver’s Home Phone:____________________
Type of Vehicle:_________________________
AUTHORIZATION AND STATEMENT OFLIABILITY: 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 Work Order:______________________________
Phase No:______________________________
Department:_____________________________________
Account No.:____________________________
Pickup Date:_____________
Time:________________
Return Date:_____________
Time:________________
Collision Insurance (Yes/No):________________
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:__________________
Driver’s Signature:___________________________
TO BE COMPLETED BY MOTOR POOL
Departure Date:_____/_____/_____
Departing Time:_______________a.m. p.m.
Returning Date: _____/_____/_____
Returning Time:_______________a.m. p.m.
Total Days:_________
Mileage:
Odometer Finish:
Odometer Start:
Total Miles:
Minimum Charge:
Amount of Charges
Per Mile x:
Total Mileage Charge:
Insurance Premium Charge:
Car Damage Charges:
Other Charges:
TOTAL CHARGES:
Vehicle Number:
Requisition #:
Comments:_____________________________________________________________
_____________________
_____________________
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Parent category: Business