Forward Completed Application and Associated Paperwork to the Travel Officer, Procurement

Form 4435.1 / Application to Use a
Private Vehicle for University Business
Office of Strategic Procurement Services / University Finance

Forward completed Application and associated paperwork to the Travel Officer, Procurement

Email: or send via Internal Mail Box 18

Please ensure all *sections are completed – form will be returned if incomplete

*APPLICANT DETAILS
Staff Student Other (Please specify)
Driver's Name: / Staff/Student Number:
CDU Email: / Phone:
Faculty / School / Division:
*DETAILS OF VEHICLE
Make of Vehicle: / Model:
Registration No: / Year:
4WD Trained? YesCopy of 4WD Certificate attached
NoIf No, a certified 4WD course is required to be completed
Comprehensive Insurance Policy Number:
I verify that I have notified my Insurer that my vehicle will be used for Business Purposes.
*REASON FOR USE OF VEHICLE (NOTE: An Approved Movement Request is required for each trip)
Purpose for which the vehicle will be used:
Length of Application/Dates/Kilometers:
Term Term Dates Km/Term
SemesterSemester Dates Km/Semester
1 YearYear Date Km/Year
Single trip only Travel Datekm/single trip
NOTE: Private Vehicle Running Sheet to be completed per mileage claim

**PLEASE SEE OVER FOR INDEMNITY** – Must be completed.

Master Document located at: W:\fas\fas-Quality Management System\Quality Management System\01 Quality System\03 FORMS\4400-4499 Procurement\4435.1ApplicationtoUsePrivateVehicleforUniversityBusiness.docx

IR# 2717R 5-02-16 Office of Strategic Procurement Services Quality Form Page 1 of 2

***INDEMNITY – USE OF PRIVATE VEHICLE WHILST ON UNIVERSITY BUSINESS***
In consideration of the Charles Darwin University permitting me to use my vehicle, I HEREBY UNDERTAKE that I will well and sufficiently indemnify the Charles Darwin University, its agents, staff members and servants and keep it and them indemnified against all claims and damages by any person which may arise out of and during the course of the use of my vehicle, as so permitted howsoever such claims shall arise.
Signature of Applicant:Date:
In the presence of (Print Name):
Witness Signature:Date:
*DECLARATION / APPLICANT SIGNATURE
I certify that I hold:

A current Driver's Licence – Expiry Date Copy attached

(both sides)

Comprehensive Insurance of the Vehicle– Expiry Date Copy attached (Certificate of Currency)
Current Vehicle Registration– Expiry Date Copy attached

4WD Certification Copy attached

Driver's Signature:Date:
*APPROVAL
I verify that I have sighted the Applicant'scurrent driver's licence / comprehensive insurance (certificate of currency), current vehicle registration, and 4WD Certificate and that they are attached to the application.
Approval delegation: VC, DVC, COO, CFO, DCOO, PVC, HOS, Director, Team Leader (VET only)
Approved Declined
Name: Delegation: / Delegation:
Signature: / Date:
This request has been declined due to:

IR# 2717R 5-02-16 Office of Strategic Procurement Services Quality Form Page 1 of 2