Division / Unit:    Employee Name:  

    Position / Title:    Contact Phone: 

    Email: 

    Trip Information

    Purpose of Trip (State Business Justification): 

    Pick Up Location: 

    Destination(s): 

    Departure Date:   Departure Time: 

    Return Date:   Return Time: 

    Estimated Total Mileage: 

    Vehicle Information

    Vehicle Type Requested (if applicable): SedanSUVVanTruckOther

    If Other: 

    Number of Passengers: 

    Special Requirements (equipment, cargo space, etc.): 

    Driver Certification

    I certify that:

    • This request is for official state business only.

    • I will comply with all state vehicle use policies.

    • I will return the vehicle in clean condition and report any damages immediately.

    Driver Signature:   Date: 

    Supervisor Name: