"Vehicle Request Form" - Connecticut

Vehicle Request Form is a legal document that was released by the Connecticut State Department of Administrative Services - a government authority operating within Connecticut.

Form Details:

  • The latest edition currently provided by the Connecticut State Department of Administrative Services;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Administrative Services.

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Download "Vehicle Request Form" - Connecticut

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VEHICLE REQUEST FORM
Agency: _________________________________________________
1
Describe the vehicle requested (vehicle class or suggested make/model
):
________________________________________________________________________
Describe how the agency will use the vehicle:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Indicate the approximate number of miles the vehicle will travel each month: _________
Indicate the approximate number of days the vehicle will be used each month: ________
Will the vehicle need special equipment? Yes _____ No _____
If yes, describe the specific equipment needed:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Will the vehicle be used to transport clients/inmates? Yes _____ No _____
If yes, indicate the approximate number of clients/inmates per trip: _____________
Will this vehicle be used for purposes other than transportation of persons (i.e.: grounds
maintenance, transportation of equipment, etc.)? Yes _____ No _____
If yes, describe the purpose. If this vehicle is to be used for the transportation of
equipment, list the specific equipment to be transported, specifying its weight and
surface area:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Will this vehicle be used to tow? Yes _____ No _____
If so, please list what will be towed, the frequency and the weight of the cargo:
___________________________________________________________________
___________________________________________________________________
Is a four-wheel drive vehicle needed? Yes _____ No _____
If yes, please describe the specific conditions that dictate this requirement:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
1
DAS retains final authority to make decision regarding make and model of vehicle.
VEHICLE REQUEST FORM
Agency: _________________________________________________
1
Describe the vehicle requested (vehicle class or suggested make/model
):
________________________________________________________________________
Describe how the agency will use the vehicle:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Indicate the approximate number of miles the vehicle will travel each month: _________
Indicate the approximate number of days the vehicle will be used each month: ________
Will the vehicle need special equipment? Yes _____ No _____
If yes, describe the specific equipment needed:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Will the vehicle be used to transport clients/inmates? Yes _____ No _____
If yes, indicate the approximate number of clients/inmates per trip: _____________
Will this vehicle be used for purposes other than transportation of persons (i.e.: grounds
maintenance, transportation of equipment, etc.)? Yes _____ No _____
If yes, describe the purpose. If this vehicle is to be used for the transportation of
equipment, list the specific equipment to be transported, specifying its weight and
surface area:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Will this vehicle be used to tow? Yes _____ No _____
If so, please list what will be towed, the frequency and the weight of the cargo:
___________________________________________________________________
___________________________________________________________________
Is a four-wheel drive vehicle needed? Yes _____ No _____
If yes, please describe the specific conditions that dictate this requirement:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
1
DAS retains final authority to make decision regarding make and model of vehicle.
Is this vehicle part of an approved facility evacuation plan? Yes _____ No _____
If yes, attach a copy of that plan.
Will the vehicle be used as a pool vehicle ___ or assigned to an individual employee___?
Provide the names, titles and duty stations of the prospective operators:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
If the vehicle is to be assigned to an individual employee:
List the license plate number(s) of the state-owned vehicle(s) (if any) previously
assigned to that employee: ____________________________________________
Has that employee received two or more moving violations while driving a state-
owned vehicle or been the subject of two or more complaints involving the use of a
state-owned vehicle in a six month period? Yes _____ No _____
If yes, explain why the employee should not be required to forfeit the
privilege of using a state-owned vehicle:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Where will the vehicle be garaged overnight? *
___________________________________________________________________
*Before any vehicle can be garaged at the home of an employee on a continuous
basis, the agency must obtain explicit approval from DAS Fleet Operations.
CERTIFICATION
• I certify the vehicle requested is essential to the conduct of agency business and is the
most cost-effective and efficient method of providing transportation to agency
employees.
• I certify that:
_____ it would be less costly to use a state vehicle than it would be to reimburse
employees for mileage travelled in their personal vehicles; or
_____ specialized circumstances, such as particular equipment needs or risk
management concerns, dictate the use of a state vehicle.
• I certify that the information provided above is accurate and correct to the best of my
knowledge.
Signature: _______________________________________ Date: ______________
Agency Head
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