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Vehicle Usage Report
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This form has been modified since it was saved. Please review all fields before submitting.
Employee Last 4 of Social Security
Report the use of ALL vehicles used for community to and from work other than authorized emergency vechicles.
Vehicle ID Number
Number of Days Used Each Month
Total Days of Use
If vehicle is used for commuting on an occasional basis, please indicate here:
By checking "I agree" you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.
I acknowledge that by typing my name here, it is the same as signing my name to a formal document
The employee is responsible for reporting vehicle usage to risk management.
Name of person completing the report, if different than above
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