Form 07-005 - Motor Pool Checkout Card Request Or Cancelation
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1State of Oregon
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DAS Fleet & Parking Services
Motor Pool Checkout Card Request or Cancelation - Form 07-005
A valid Motor Pool Checkout Card must be presented at the time a vehicle is dispatched. If one is
not presented, the customer may be turned away. This card is authorization for vehicle use and the
to bill the agency.
information is used
ately if the Motor Pool Checkout Card is no longer
Agency must notify DAS Fleet & Parking Services immedi
authorized for use. Agency is responsible for all vehicle charges until DAS Fleet & Parking Services is
notified of card cancelation.
Please specify purpose of request
Request new checkout card(s).
(fill out sections A - B)
Cancel card #(s) (five digits at bottom left of card): ________________________________________________________________
(fill out section A - B)
Reason for canceling card(s): ________________________________________________________________________________________________
Six-Digit Agency Number
Quantity of Cards Requested
Cost Center (17 character maximum)
Agency Name
Unit/Section Name
Contact Name
A
Mailing Address
Zip
City
Phone
E-mail
REQUESTING AGENCY APPROVAL
I authorize issuance / cancellation of Motor Pool Checkout Cards for the agency accounts referenced on this application.
I understand the Motor Pool Checkout Card will be used within the guidelines established in all applicable
Administrative Rules, Oregon Statutes, and Agency Policies.
B
Signature of Agency Head or Designee
Printed Name
Date
MOTOR POOL USE ONLY
Card Numbers
□
□
Billing Approval: __________________________
Date: _________________________
Issued
Canceled
Date: _________________________
Entered/Canceled: __________________________
Date: _________________________
Proofed and Mailed: __________________________
Send or Fax to: DAS Fleet & Parking Services, 1100 Airport Rd SE, Salem, OR 97301-6082
Phone: (503) 378-4377
Fax: (503) 378-5813
07-005
Rev. 10/26/2016
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