Free maintenance request form 53
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CAL POLY
POMONA
FACILITIES PLANNING AND
MANAGEMENT

Vehicle Maintenance Request Form
Please complete this form to update our vehicle maintenance records. The information provided will be updated once
per fiscal year. If chargeback information changes during the fiscal year a new form will need to be submitted with the
updated information and approvals. All forms should be completed and returned within two (2) weeks of receiving
them. Should you have any questions, please contact our Facilities Customer Service team at: (909) 869-3030.
*Requestor:

Email:

Date:

Department:

Phone:

Fax:

Vehicle number(s):
*This should be the primary point of contact for the vehicle maintenance

Send chargeback statement to:
Funding source:

Account

Name:

Email:

Fund

Dept ID

ASI PO#:

Program

Ext:

Class

Project

Foundation Account:

Services requested (check all that apply)
Fuel Charges
Annual Service

Misc. Repairs

Other (please describe):

Authorized Signer’s Name (please print)

Title or D