ADMV-105 rev 4/2009
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF ADMINISTRATION - TRANSPORTATION SERVICES
REQUEST FOR TEMPORARY ASSIGNMENT
License Plate
Department Division Appropriation Acct. No. to be Billed
Date Requested From To Total Days
Driver’s Name (Print or Type) Driver’s Home Address Driver’s License No.
Authorization Signature Title
Transportation Use Only
Class
Out
Date Odometer Time By
In
Date Odometer Time By
Days Used Days Not Charged Reason Correction
Driver Taking Car
Before moving car from parking place: Check and report to dispatcher any visible damage, inoperable
lights, horn directional signals or windshield wiper. Check spare tire to be sure it is not flat. Check that
inspection sticker on windshield is current, and that insurance card is present and current. Otherwise as last
driver, you are required to file and accident report. Subsequent accidents or damage must be reported
immediately.
Driver Returning Car
Driver certifies that car is returned in good condition, except for:
Brakes
Tires
Glass
Steering
Lights
Wipers
Engine
Transmission
Signature of Driver Receiving Car Signature of Driver Returning Car
