Trip Request
Department: _______________________________________________________ _____
Driver’s Name(s):_____________________________________ ___________________
Driver’s License No: ____________________________ Issuing State: ______________
Start Date: ___________________________ Return Date: _______________________
Total Trip Miles: _____________________
From: ______________________________ To: _______________________________
Reason for Trip: _________________________________________________________
Vehicle No: _________ Vehicle Tag No: ______________________________________
By signing this report, I acknowledge that I have:
1. A valid Driver’s License
2. Not had my driver’s license suspended or revoked within the past three years
3. Passed the Safe Driving Course on (Date) ______________ for 15-passenger vans I also give my
permission to the CollegePolice Department to do a background check and give the results to my
department chair/head.
Print Name: ____________________________________________________________
Sign Name: ____________________________________________________________
Date:
_____________________________________ ______________________
Department Head Signature Date
Effective July 1, 2018
Mississippi Delta Community College does not discriminate on the basis of race, color, national origin,sex,disability, or age in its programs
and activities. The following person has been designated to handle inquiries regarding the nondiscrimination policies: The Associate Vice
President of Institutional Effectiveness, Boggs-Scroggins Student Services Center, P.O.Box668, Moorhead, MS 38761,662-246-6558.
