REQUEST FOR POOL VEHICLE

DETAILS OF DRIVER KILOMETRES

Name & Surname: JEREMY VAN DER MERWE Start Kilo's:
Driver's License no: 60500000BXSK End Kilo's:

License Valid From 11/9/2015 To 14/09/2020 Total Travelled

PASSENGERS: 1. 2.

3. 4.
TRIP DETAILS
Reason for Trip COURT

FROM BETHLEHEM JC HARRISMITH COURT

FROM HARRISMITH COURT BETHLEHEM
FROM TO
VEHICLE CONDITION
DETAILS BEFORE TRIP AFTER TRIP
YES NO YES NO COMMENTS
RADIO/SPEAKERS x x
PETROL CARD x x
SPARE WHEEL x x
WHEEL SPANNER x x
JACK x x
DAMAGES/SCRATCHES x x
FUEL x x
Water x x
Renewal of lisence date
TYRES x x
VEHICLE DETAILS
MAKE & MODEL: REGISTRATION NO:
ADMINISTRATION
DRIVER'S SIGNATURE Name of Manager approving LORRAINE/WOUTER
DATE 28/10/2016 SIGNATURE
DATE 28/10/2016
VEHICLE ISSUED BY: L. RAMABODU
SIGNATURE:
Declaration:
I declare that my license is valid, and is not qualified by any indorsement, I undertake to drive the vehicle with care and not to
abuse or use the vehicle for any personal gain. I'm aware of the policies of the Legal Aid SA applicable to the use of motor
vehicles. I acknowledge that in the event of contravening the policy, I will be held liable for the damage, loss or cost suffered
as a result of my negligence. I further acknowledge that i have inspected the vehicle on taking possesion and will co-operate
for the inspection upon return