7/25/2019 Motor Vehicle Request

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MOTOR VEHICLE TRIP TICKETU.S. GOVT TAG NO.

PART III. For use of Dispatcher, Driver, and User (Continued)

PART I. For Use of Requesting and Approving Offices SERVICES AND SUPPLIES PROCURED FROM COMMERCIAL FACILITIES

REQUESTED BY(Organization or individual) USERS NAME(Print or type) COST

Rehabilitation Research ITEM UNIT QUANTITY(Gallons

o !"el#

UNIT TOTA$

OFFICIAL PURPOSE(See note on reverse side of form) GAS RECEIPT IS REQUIRED !"elTo travel with postdoctoral research associate, Dr. Junping Xin to St Louis to attend theannual meeting of the Society for Neurochemistry. Dr. Mcuire and Dr. Xin will !egiving a presentation and Dr. Mcuire also will attend the "SN #ouncil meetings..

!"el

PLANNED ITINERARY !"el %&'M ( T' )ST. D*&"T+'N '% !"el

Total !"el A%%e% PREVENTIVE MAINTENANCE SERVICES (Indicate condition of items listed below by S satisfactory, or

Uunsatis actor .)

FUEL BRAKES ENGINE CONTRO$S

CRANKCASE OIL CLUTCH !EN&ERS AN& 'O&Y

WATER STANDARD FORM 91. operators REPORT OFMORTOR VEHICLEACCIVENT

TIRES

!irst entr) *"st be the +lace ,ehicle is to re+ort. LEAKS-GENERAL WINDSHELD WIPERS VE-IC$E $OA&

REQUESTED FOR(ate and time) RETURN PICK-UP(ate and time) INSTRUMENTS GLASS TOO$S AN& EQUIMENT

HORN LIGHTS AND REFLECTORS

REQUESTING OFFICIAL(Signature) APPROVED BY(Signature) REMAR/S0 (!"plain unsatisfactory condition of items mar#ed $U% above& describe any ot'er defects noted w'ile

performing $beforeoperation,% and $afteroperation% services as outlined in manual ***+*& and in event ofaccident, ma#e reference to attac'ed Standard orm -*.)

PART II. For use of Dispatcher, Driver, and User Motorool a1 2 3 456375737468TRIP OR LOAD RECORD PASS. OR WT. SPEEDOMETER READING

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