STATE OF CALIFORNIA
AUTHORIZATION TO USE PRIVATELY OWNED
VEHICLES ON STATE BUSINESS
STD. 261 (REV. 3-95)
This approval must be renewed annually.
Supervisor: Retain Original Copy
I. CERTIFICATION
In accordance with State Policy (S.A.M. 0753 & 0754) approval is requested to use privately owned vehicles to conduct official State business.
I hereby certify that, whenever I drive a privately owned vehicle on State business, I will have a valid driver's license and proof of liability insurance
in my possession, all persons in the vehicle will wear safety belts and the vehicle shall always be:
1.
Covered by liability insurance for the minimum amount prescribed by State Law ($15,000 for personal injury to, or death of one person;
$30,000 for injury to, or death of, two or more persons in one accident; $5,000 property damage). Vehicle Code Section 16020 (effective
July 1, 1985) requires all motorists to carry evidence of current automobile liability insurance in their vehicle.
2. Adequate for the work to be performed.
3. Equipped with safety belts in operating condition.
4. To the best of my knowledge, in safe mechanical condition as required by law.
I understand that the mileage rate I claim is full reimbursement for the cost of operating the vehicle, including fuel, maintenance, repairs
and both liability and comprehensive insurance.
I further certify that, while using a privately owned vehicle on official State business, all accidents will be reported on form STD. 270 within 48
hours (S.A.M. 2441).
I understand that permission to drive a privately owned vehicle on State business is a privilege which may be suspended or revoked at any time.
DRIVER'S LICENSE NUMBER STATE
EXPIRATION DATE
DATE SIGNED
EMPLOYEE'S SIGNATURE PRINT NAME
II. APPROVAL
Use of a privately owned vehicle on State business is approved.
APPROVING AUTHORITY SIGNATURE TITLE DATE APPROVED
III. RENEWAL
I have reviewed the above certification and approval and certify that the information provided is correct and valid.
APPROVING AUTHORITY SIGNATURE
EMPLOYEE'S SIGNATURE
DATE APPROVED
I have reviewed the above certification and approval and certify that the information provided is correct and valid.
EMPLOYEE'S SIGNATURE APPROVING AUTHORITY SIGNATURE
DATE APPROVED
I have reviewed the above certification and approval and certify that the information provided is correct and valid.
EMPLOYEE'S SIGNATURE
APPROVING AUTHORITY SIGNATURE
DATE APPROVED
I have reviewed the above certification and approval and certify that the information provided is correct and valid.
EMPLOYEE'S SIGNATURE APPROVING AUTHORITY SIGNATURE
DATE APPROVED
I have reviewed the above certification and approval and certify that the information provided is correct and valid.
APPROVING AUTHORITY SIGNATURE
EMPLOYEE'S SIGNATURE
DATE APPROVED
I have reviewed the above certification and approval and certify that the information provided is correct and valid.
EMPLOYEE'S SIGNATURE
DATE APPROVED
APPROVING AUTHORITY SIGNATURE
I have reviewed the above certification and approval and certify that the information provided is correct and valid.
DATE APPROVED
EMPLOYEE'S SIGNATURE
APPROVING AUTHORITY SIGNATURE
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