Southern University at Shreveport
University Vehicle Request and Responsibility
SECTION A:
__________
VEHICLE REQUEST
Driver: _________________________________________________ Department: __________________________________________
Destination:
__________________________________________________________________________________________________
Purpose: ___________________________________________________________________________________________________________
Requested Vehicle (s): #1___________________________________
#2_____________________________________________
Date & Time vehicle will be needed: ___________________________________________________________________________
Approval of Department Head (if applicable):
______________________________
Date:_____________
Approval of Department Vice Chancellor: __________________________________________
Date: _____________
SECTION B:
DRIVER’S RECORD – (TRAVEL OFFICE)
Has driver completed Driver Safety Course?
SECTION C:
__________________ Yes
______________________ No
APPROVAL SIGNATURE
Vice Chancellor for Finance and Administration: _________________________________
SECTION D:
Date: ____________
UNIVERSITY POLICE RESPONSIBILITY
CHECK-OUT INFORMATION
Name of Officer releasing vehicle: _________________________________________Date: ______________________________
Type Vehicle Assigned: _________________________________________________________________________________________
Date of Release: _____________ Time of Release: ___________ Gas Card Number issued:__________ ____________
Vehicle Released to: (Signature) _____________________________________________________________________________
RETURN OF VEHICLE INFORMATION
Officer accepting returned vehicle:__________________________________________________________________________
Date vehicle returned: _________________________________ Time Returned: ____________________________________
Signature of driver returning vehicle: _______________________________________________________________________
Southern University at Shreveport
Revised 03/2009