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Application for Permanent Assignment of Passenger Vehicle

Person Assigned to or Responsible for the Vehicle
Name:     
Drivers License No.:   State Driver's License Issued From:   
Position Title:   
Work Phone No:  Ext:    
Work Mailing Address: 
 (if working from home, enter home address)
Work City:     Zip:   Courier/MSC: 
Email:     
Vehicle Usage:   
Department or Institution Information
Department:     
Company:     Fund No.:    Center No.: 
Division, Office or Agency Information
Name:   
Phone No:  Ext:     
Address:   
City:    Zip:  Courier/MSC: 
Address Vehicle Will be Parked:    City:  
County Vehicle Will be Parked:   
Additional Information
Section(if applicable): 
District(if applicable): 
Vehicle Needs
Date Needed(mm/dd/yyyy):     
How Long Needed:   
Expected Yearly Mileage Use:   
Why Vehicle is Needed and
How it Will be Used: 
 
Type Vehicle Needed: