Fillable Vehicle Assignment Form - State Of Iowa printable pdf download

No:___________

State of Iowa

Central Procurment & Fleet Services Enterprise

Vehicle Assignment Form

CHECK ONE BOX ONLY

DNR ONLY

Summer Activation

Replacement

Return

New Vehicle to Agency Fleet

(complete form to dotted line)

Reregistration

Driver Change

Summer Deactivation

(complete Return portion)

If reregistration, old vehicle no. __________________________

_________________________________________________________________________________________________

_________________

DEPARTMENT AND DRIVER INFORMATION

Fleet Services must be notified immediately on this form of any changes in assignment. This information shall be kept current.

Vin No

Vehicle No: ___________________________

:____________________________________________________________________________

Accounting string to be charged:_

________________________________________________________________________________________________________

Agency Name

:_____________________________________________________________________________________________________________________________

Driver Name:____________________________________________________________________________________________________

Driver License No:________________________________________________________________________________________________

Domicile Address:________________________________________________________________________________________________

Domiclie City, State, Zip Code:_______________________________________________________________County:________________

Driver's Cell Phone No: ____________________________________ Driver's Work PhoneNo:_

___________________________________________

____________________________________________________________________________________________________________________________________________

I hereby acknowledge responsibility for operating this vehicle in accordance with the policies contained in the Fleet Services Policies and Procedures Manual and rules in

Chapter 103 of the Administrative Code. I agree to maintain and operate this State of Iowa vehicle in a conscientious manner.

Driver's Signature:______________________________________________________________________________________________________________________

I hereby request the use of a state vehicle for conducting state business within the scope of my agency. I realize my agency is responsible for the care and proper maintenance

of this vehicle and insuring that this vehicle is operated in accordance with the published and administrative rules.

Departmental Authorization:_____________________________________________________ Date: ____________________________________________________

---------------------------------------------------------------Fleet Use Only

----------------------------------------------------------------------------------------------

ISSUE

Date:________________________________

Odometer:_____________________

Vehicle Year:_________________ Make: _____________________________

Model:_______________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

RETURN

Date: ___________________________

Odometer: ___________________________

VIN: _____________________________________________________________

Vehicle No:____________________

Location:

Auction

Unassigned

Accident/Salvage

Received by: __________________________________________

Please email completed form to: VAFmailbox@iowa.gov