Yes No
USE OF:
2 Vans/15 seats* #A53, A54
# vans needed
5 Vans/8 seats #A56 to A60 Other District Vehicle
trucks or golf carts
Gas/Voyager Card Rental Vehicle**
Gas/Voyager Card ONLY
FOR:
Cross Ctry
Swimming
& Diving
Forensics Men's Soccer Women's Soccer
Men's Basketball Women's Basketball
Fire Science Tech
Has a field trip request been completed?
Other Use State Purpose & District Vehicle Requested:
DESTINATION
VEHICLE/CARD PICK UP
Date Time
DEPARTURE
Pick up:
GAME OR EVENT
Return:
RETURN
TRANSPORTATION FOR
# of Students + # of Faculty/Driver(s) =
DRIVER(S) NAME
Must be at least 25 years of age w/valid CA driver's license on file and approved as a driver by M&O to drive a District Vehicle
*
Class B Commercial license with passenger endorsement for 15 required for Van Drivers or
*Commercial License required
for some District Vehicle use
*
Class B Commercial license with passenger endorsement for 25 required for Bus Driver &
*
DMV Medical Examiner's Certificate must be on file w/ District M&O to transport students.
Please check here if using Rental Vehicle from a Rental Agency**
**Your Dept is responsible for vehicle rental, delivery, pick up, vehicle return, and All rental fees.
**You must return vehicle with proper fuel to the Rental Agency.
**Submit all rental agency receipts with copy of form to the LPC Administrative Services Office
REQUESTED BY:
APPROVED BY***:
Administrator
***Approval of this request to use a District Vehicle or a Voyager Fleet Gas Charge Card authorizes the Department
to reimburse the District for District Vehicle mileage charges at reimbursement rate per mile and any Voyager card
charges for fuel or repairs will be charged to the Department Acct # authorized on this Vehicle Reservation Form
ACCOUNT NUMBER:
ACCOUNT INFO MUST BE COMPLETED to ensure accurate expense posting
*** SUBMIT ALL VOYAGER CARD RECEIPTS TO M&O OFFICE WITH DRIVER PACKETS UPON RETURN
Completed by M&O Office: Date Received by District M&O Office at LPC
Using Rental Vehicle Yes No
District vehicle available at LPC:
Verified Driver on approved District Driver List and All Records up to date:
Distribution:
Department District Acct. LPC Admin Svcs M&O Office LPC
01/30/2012
LPC REQUEST FOR USE OF DISTRICT VEHICLE/GAS CARD
Submit completed request to District M&O Office at LPC at least 2 weeks prior to departure date
NO REQUEST ON FILE WITH DISTRICT M&O OFFICE AT LPC = NO VEHICLE or NO GAS CARD
VEHICLE/GAS CARD
completed by M&O Office
Date Time
Date Time
Date Time
NoYes
#
# vans needed
#
Rental vehicles only
Field Trip -
Vehicle Type, Size, and # passengers
