Free 34193.FH11 - Indiana

VEHICLE USE AGREEMENT

State Form 34193 (R5 / 12-04) DEPARTMENT OF ADMINISTRATION OPERATIONS DIVISION - STATE MOTOR POOL 601 W. MCCARTY STREET, SUITE 125 INDIANAPOLIS, IN 46225 (317) 232-1378

Date of request

Commission number

License number

A travel log for each permanently assigned vehicle must be submitted to the Motor Pool Accounting Section by the 10th working day of each month. Type of assignment (check one) Temporary Year Telephone number Model Driver's job classification Driver's license number Date of birth Make Permanent Vehicle purchase price Vehicle identification number

INSTRUCTIONS: Form must be completed with typewriter.
Name of department or agency Division and account number Name of driver Address (number, street, city, state and ZIP code)

Location official station Location of vehicle off duty parking lot Distance from home to official station Distance from vehicle off duty parking to official station Distance from home to State Office Building

NOTE: If location of vehicle off duty parking differs from location of official station, a statement of justification is required. Use attachment.
Time out AM PM Date vehicle issued Ending mileage Beginning mileage Total days used Dispatcher Vehicle damage (at time of issuance or turn-in) repairs required Number of passengers Type of cargo transported Date vehicle returned Time in AM PM Purpose of travel / Destination Lease rate

User agency agrees to the following: 1. 2. 3. 4. 5. Agency head or designee assumes responsibility for monitoring vehicle use by the assigned driver(s) with regard to compliance with existing state laws, rules, regulations, and guidelines. It is understood by the agency head and assigned driver(s) that this vehicle in NOT to be operated for any personal uses including, but not limited to, commuting or the transporting of other than state employees or agency clients on official business. When not in use on official business (e.g. holidays, weekends, overnight), this vehicle is to be parked adjacent to the driver's official station. Any exception to the parking stipulation must be justified by attachment (e.g. law enforcement personnel on 24-hour duty call). Maintenance of the vehicle according to manufacturer's specifications and keep vehicle road-worthy and clean. The State of Indiana assumes no responsibility for the safety or security of private property left on the premises.

I do hereby certify that I will abide by the policies and requirements of Signature of department head requesting vehicle for assignment the Indiana State Motor Pool.
Signature of driver

DISTRIBUTION: White - General Services; Canary - Agency; Pink - Motor Pool Garage