2015 Service Vehicle Requisition Complete this form for each vehicle requested

Requestor Name

First NameLast Name

Date of Request

Date

Phone Number

Area CodePhone Number

Email Address:

example@example.com

Department:

Facility Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Garage Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select Vehicle Type (Car, Van, Pickup, Bus, Other)

Street Legal?

YesNo

Detailed Vehicle Job Function:

Additional Equipment (e.g. Lift Gate, Trade Package, Shelving, Roof Racks, Wheelchair Access Stake Bed, HVAC, Security Lighbar, etc.):

ALL VEHICLE REQUISITIONS ARE TO BE FULLY APPROVED BY THE APPROPRIATE MANAGER AND THE CORRESPONDING FINANCIAL OFFICER AT YOUR MEDICAL CENTER

Vehicle Information (select one):

Replacement?Addition to the Fleet?

AFO Name:

AFO Email:

Manager Name:

Manager Email:

Year, Make and Model:

License #:

Mileage:

Condition of Vehicle:

Please complete the questions below for all vehicle requests

What will this vehicle enable you to accomplish and why is your existing complement of vehicles inadequate of unsuitable?

Explain how this vehicle will reduce your long-term cost structure. If a cost/benefit analysis has been performed, please attach copy.

Describe the impact on your program if this item is not approved for funding.

What other means has been considered to achieve this improvement?

FLEET OPERATIONS ADMINISTRATIVE USE ONLY

Date Requisition Entered:

Date

Requisition#:

Estimate Cost:

Has AFO email approval been secured?

YesNo

Does vehicle to be retired meet KP"s replacement policy?

YesNo

Does purchase follow KP"s Fuel Strategy?

YesNo

Vehicle Requisition Form

Vehicle Request Details