Commissioner Darin R. Seeley

Forms

Vehicle Assignment - Replacement Form

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Fill in the following information and click the Submit button to submit the request to Fleet & Travel Management.

Driver Information

Name:

* Required

Mailing Address:

[full address with zip]

* Required

Office Phone:

Ex. (555)555-5555

Home Phone:

Ex. (555)555-5555

Mobile Phone:

Ex. (555)555-5555

Fax:

Ex. (555)555-5555

Department Name:

Department MSA Center Number:

* Required

Department Account Number:

* Required

Contact the fiscal officer if you do not know the Account Number.

Submitter Information

Submitter Name:

* Required

Submitter Email:

* Required

Submitter Work Phone:

Ex. (555)555-5555

* Required

Other Information

City where vehicle will be located:

* Required

Average miles driven per month:

* Required

Number of passengers in vehicle most of the time:

* Required

Existing vehicle license number:

[i.e. AG212, CH212]

* Required

Odometer reading on existing vehicle:

* Required

Type of vehicle requested:

* Required

Type of transmission:

* Required

Type of fuel:

* Required

Kind of equipment carried in the vehicle:

* Required

Type of road terrain the vehicle will be traveling on:

* Required

Explanation of the need for a replacement vehicle:

* Required