Passenger Van Rental Request Form

Please select the number of vehicles you are requesting and input all applicable information as requested. If you have any questions, please contact the Parking Office at 817-272-3907.

Number of Vehicles Requested
Phone Number Phone Number - ### - ### ####
UTA Requesting Department
Cost Center
Contact Contact Title First Last Suffix
Estimate Miles
Number of Passengers
Purpose of Trip (reason for vehicle rental)
Destination State Destination State
City State / Province / Region
Departure Date Departure Date / MM / DD YYYY
Return Date Return Date / MM / DD YYYY
Authorized Driver 1 - Name Authorized Driver 1 - Name First Last
Does Authorized Driver 1 have EH&S 15-passenger van training?

Does Authorized Driver 1 have EH&S 15-passenger van training? Yes No
Is there more then 1 Authorized Driver?

Is there more then 1 Authorized Driver? Yes No
Authorized Driver 2 - Name Authorized Driver 2 - Name First Last
Does Authorized Driver 2 have EH&S 15-passenger van training?

Does Authorized Driver 2 have EH&S 15-passenger van training? Yes No
Authorized Driver 3 - Name Authorized Driver 3 - Name First Last
Does Authorized Driver 3 have EH&S 15-passenger van training?

Does Authorized Driver 3 have EH&S 15-passenger van training? Yes No
Authorized Driver 4 - Name Authorized Driver 4 - Name First Last
Does Authorized Driver 4 have EH&S 15-passenger van training?

Does Authorized Driver 4 have EH&S 15-passenger van training? Yes No
Department Authorization

Departmental representative identified in this section confirms that the Rental Requester named herein is approved to submit request for use of a university vehicle for the purpose described on request form.
Department Approver Name Department Approver Name First Last
Department Approver Email Address
Rental Requester Name Rental Requester Name First Last
Rental Requester Email Address
Requester Confirmations
Please read the following statements. Check the box for each statement to confirm understanding of and agreement to the stated requirements for vehicle rental requests.

Please read the following statements. Check the box for each statement to confirm understanding of and agreement to the stated requirements for vehicle rental requests. Upon approval, the requesting department is able to pick up key(s) on or the day before the reserved date by 4pm (weekend usage only). Vehicles returned before 8am will not be charged. If department has a vehicle reserved prior to weekend and it is not returned by Friday at 4:30pm then charges will be incurred for weekend use at $60.00 per day. Requestors will receive an electronic confirmation via email. If you need to cancel your request, please contact the Parking Office at 817-272-3907 within 24 hours of scheduled date. Results not in compliance with cancellation policy may result in daily charges to your account. Driver(s) must be authorized to drive a University vehicle and comply with all driving record and training procedures under University of Texas Arlington Procedure 8-6. You may be entitled to know what information UT Arlington (UTA) collects concerning you. You may review and have UTA correct this information as applicable in accordance with procedures set forth in UT System BPM #32. The law is found in sections 552.021, 552.023 and 559.004 of the Texas Government Code.
I have read the above confirmation information and agree to comply with all criteria requested of me and/or my department.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.