Carpool vehicles are reserved on a first come, first served basis. Reservations can be requested by completing this application.
Pickup and ReturnCarpool packets and vehicles are available 24 hours per day, 7 days a week. Since the carpool packets and vehicles are onsite your pick up and return date and time should coincide with actual travel dates. The carpool vehicles should not be parked at your residence overnight for early morning or Monday travel, unless preapproved by the OA Carpool Administrator.
Pickup Date
Pickup Time
Return Date
Return Time
Actual Travel Date (if different from pickup and return time)
Destination
Instructions on this field: If there are multiple cities that you will travel to, please enter all of your stops so that we can estimate your round trip miles. For example: Jefferson City to St. Louis to Cape Girardeau to Jefferson City.
Will the vehicle travel outside of state lines? No - the vehicle will not travel outside state lines Yes - the vehicle will travel outside state lines
Are you traveling to an airport? --Please select one -- No - I am not traveling to the airport. Yes - I am traveling to the airport.
Driver/Vehicle Information
Full Name (As it appears on driver's license)
*Driver's License Number *Do not provide your Social Security Number in this form. First-time users may be contacted to provide additional information for purposes of driver’s license verification.
Are you a state employee? Yes, I am a State employee. No, I am not a State employee.
Vehicle Type Needed Sedan Minivan
Passenger
Information: Number of Passengers (if you do not have any passengers, there is no need to continue with the rest of the passenger information. Please skip to the Billing Information. If greater than one, you must continue with the following questions.
Any Passengers? I do not have any passengers. I have one or more passengers.
Will any of the passengers drive? No Yes
Is the passenger a state employee? Yes, the passenger is a State employee. No, the passenger is not a State employee.
Provide full name and driver's license number of any passengers that may drive the state vehicle (Do not include a Social Security Number!):
Billing Information
Agency Name
Division Name
SAM II Customer Code (if known)
Contact Information
Contact Name
Contact Email Address
Contact Phone
MO 300-1864 (7-05)