Vehicle Use

Information

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* = required field

Site Information

*Site you are registering for:

SIUC

You may have the opportunity to request permission for additional sites after you are approved for your primary site. Request for additional permissions is done via the My Profile link.

User Information

(*Last Name, *First Name, ):

*Username:

*Login Password:

*Re-enter Password:

Contact Information

Organization:

Title:

Department:

*AIS Budget Purpose:

Address:

Address (contd).:

City:

State/Province:

Zip/Postal Code:

Country:

*Phone Preference:

*Business Phone: Ext

Mobile Phone: Ext

Fax: Ext

Other: Ext

Preferred Email:

*Work Email:

Personal Email:

DOB:(MM/DD/YYYY)

Additional Information

*Fiscal Officer Name:

*Fiscal Officer Phone:

*Fiscal Officer Email:

*Driver's License Number:

*License Expiration Date:(MM/DD/YYYY)

*License Issuing State/Province:

Any driving restrictions? Yes No

If restrictions, please explain:

Use the space below to provide:
1) A description of your motor pool requirements,
2) Any unique requirements you may have (e.g. Always require cargo space, require wheelchair lift), and
3) Any other comments you may have for the motor pool staff.

Note: Please do not enter driver's license numbers in this space.

Please enter the text you see in the picture into the text box before submitting your registration.

Drive Safe!