NOTE:  THIS FORM MUST BE SUBMITED TO THE VEHICLE ASSIGNMENT OFFICE ONE WEEK PRIOR TO THE TRIP DATE.

Name of Supervising Staff Member Making  Request:_________________________________

Date(s) of Trip:______________________________

Destination:                   ________________________________________________________

Purpose of Trip:_____________________________________________________________

                            _____________________________________________________________

Reason for Use of Student Driver:___________________________________________________________

           Student Driver(s) Requested:

A COPY OF THE STUDENT’S DRIVER’S LICENSE
MUST BE ATTACHED TO THIS FORM.

NAME                                          SOCIAL SECURITY NO.
___________________________________________

___________________________________________

___________________________________________

___________________________________________

In accordance with the “Policy on Students Operating College Vehicles,” I request the student(s) listed above be authorized to operate a College Vehicle during the trip indicated.

______________________________
 Signature of Supervising Staff Member                   Date  _______________________________

______________________________
Signature of Department Chair                                  Date________________________________

______________________________
Signature of Appropriate Dean or VP                       Date________________________________

_________________________________
Approval by Vehicle Assignment Office  Date