U.S. GOV’T TAG NO.

MOTOR VEHICLE TRIP TICKET PART III.  For use of Dispatcher, Driver, and User (Continued)
PART I.  For Use of Requesting and Approving Offices SERVICES AND SUPPLIES PROCURED FROM COMMERCIAL FACILITIES
REQUESTED BY (Organization or individual) USER’S NAME (Print or type) COST
Rehabilitation Research ITEM UNIT QUANTITY UNIT TOTAL
(Gallons
of Fuel)
OFFICIAL PURPOSE (See note on reverse side of form) GAS RECEIPT IS REQUIRED Fuel
To travel with postdoctoral research associate, Dr. Junping Xin to St Louis to attend the annual meeting of Fuel      
the Society for Neurochemistry. Dr. McGuire and Dr. Xin will be giving a presentation and Dr. McGuire also
will attend the ASN Council meetings..

PLANNED ITINERARY Fuel      

1
FROM TO  EST. DURATION OF Fuel      
Total Fuel Added      
PREVENTIVE MAINTENANCE SERVICES (Indicate condition of items listed below by S  satisfactory, or
U unsatisfactory.)
FUEL BRAKES ENGINE CONTROLS

CRANKCASE OIL CLUTCH FENDERS AND BODY

STANDARD FORM 91. operator’s REPORT OF
WATER MORTOR VEHICLE ACCIVENT TIRES
1
First entry must be the place vehicle is to report. LEAKS-GENERAL WINDSHELD WIPERS VEHICLE LOAD
REQUESTED FOR (Date and time) RETURN PICK-UP (Date and time) INSTRUMENTS GLASS TOOLS AND EQUIPMENT
HORN LIGHTS AND REFLECTORS

REQUESTING OFFICIAL(Signature) APPROVED BY (Signature) REMARKS: (Explain unsatisfactory condition of items marked “U” above; describe any other defects noted while
performing “before-operation,” and “after-operation” services as outlined in manual M11-101; and in event of
accident, make reference to attached Standard Form 91.)

PART II.  For use of Dispatcher, Driver, and User

MotorPool fax # - 708-202-2789
TRIP OR LOAD RECORD PASS. OR WT. SPEEDOMETER READING
FROM

TO
E85- Locator – http://www.e85refueling.com/
TO
Or www.afdc.energy.gov/afdc/locator/stations/
TO
GAS CARD INSTRUCTIONS:
TO
1. Insert gas card as instructed.
TO
2. GAS RECEIPT IS REQUIRED.
TO
3. It will ask for your ID. This is 6 digits of the license plate number.
TIME DATE SPEEDOMETER READING The number is also located on the bottom left side of the gas card.
IN IN
4. Press Enter
OUT OUT
5. Enter the odometer reading and press Enter.
TOTAL TIME OF TRIP TOTAL MILES DRIVEN ON TRIP
6. Lift nozzle and select grade. Select low octane / or E-85 for flex fuel vehicles
HOURS MINUTES
7. Begin fueling.
This motor vehicle has been used for the official purpose stated above. (See note on
reverse side of form.)
I have reported all services and supplies procured from commercial facilities,
performed the preventive maintenance services listed, and reported any accident. Yo 8. Record fuel USAGE and TOTAL in Part III above.
Note. - Any officer or employee of the Government who willfully uses or authorizes the use of any
Government-owned passenger motor vehicle . . for other than official purposes . . shall be suspended
from duty by the head of the department concerned, without compensation, for not less than one month,
(SIGNATURE OF USERS) (SIGNATURE OF DRIVER) warrant (5 USC 78(c)2).

Automated VA Form 90-3075