Campus Programs & Services

Requester Information

Request made by:*

First

Last

Phone*

Email*

Group Name*

What type of group?*

Student Group
University Department

Number of Vans Requested:*

One
Two

Primary Driver (Van 1):*

First

Last

Van 1 Primary Driver Cell Phone:*

Primary Driver (Van 2):*

First

Last

Van 2 Primary Driver Cell Phone:*

Will there be any additional drivers?*

Yes
No

First Additional Driver:*

First

Last

First Additional Driver Cell Phone:*

Second Additional Driver:

First

Last

Second Additional Driver Cell Phone:

Number of occupants for van 1 (driver + passengers):*

Please enter a value between 0 and 12.

Number of occupants for van 2 (driver + passengers):*

Please enter a value between 0 and 12.

Single day or multiple day trip?*

Single Day
Multiple Day

Date Requested for Use:*

First date requested for use:*

Last date requested for use:*

Van check-out time (first or single day):*

HH
:

MM

Van check-in time (single or last day):*

HH
:

MM

Destination:*

Local (within Winston-Salem)
State (within North Carolina)
Out of state

NC Destination:*

Out of State Destination:*

Purpose of trip:*

Department/Organization Name:*

Approval Name*

First

Last

Approval Email*

Budget Code:*

*

I agree to the Terms and Conditions above.

Phone

This field is for validation purposes and should be left unchanged.

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Daily Rental Rates (per van):

Terms & Conditions

Requester Information

Group/Driver Information

Trip Information

Payment Information

Terms and Conditions

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Campus Programs & Services