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Executive Motor Pool Request Form

*Required to Schedule Motor Pool Transportation.

*1.	Approved user contact information:
	Name:
	Email:
	Phone:
	Title:
	OpDiv/StaffDiv:
2.	Requester Contact Information (if other than user):
	Name:
	Email:
	Phone:
*3.	Total number of passengers in the party:
*4.	Desired date and time for pickup:
	Date:
	Time:
*5.	Special needs equipped vehicle required? Yes or No (If yes, please state requirements below. 24-hour advance notice required.)
*6.	Pickup Location:
	Address line 1:
	Address line 2:
	City:
	State:
	Mobile phone or contact number at pickup location: ext.
*7.	Destination:
	Address line 1:
	Address line 2:
	City:
	State:
*8.	Will return transport be required? Yes or No (If yes, please provide additional information below)
	Desired date and time for return transport pickup:
	Date:
	Time:
	Mobile phone or contact number at pickup location: ext.
*9.	Will the driver be required to wait? Yes or No Drivers are authorized to wait for up to 15 minutes when picking up a Motor Pool passenger. The period may be extended, based on availability. Please provide wait time information on the next line.
10.	Anticipated wait time, if applicable:

Please note:

When possible, requesting service one business day prior will permit the Executive Motor Pool to schedule resources that precisely meet your needs. If advance notice cannot be provided, every effort will be made to be as responsive as resource availability permits.

Service requests for disabled employees requiring specialized transportation must be made at least 24 hours in advance to ensure availability.

This service is provided by PSC in accordance with the HHS Executive Motor Pool Policy dated August 4, 2005. If you have any questions or need assistance, please contact Gary Boykin. Phone: 202-619-2140; Email: gary.boykin@psc.hhs.gov.

Program Support Center (PSC)

Executive Motor Pool Request Form