Gas Receipt Form
For District Van and Fuel Card Use
Gas Receipt Form
| Travel date(s): | Van number: | |||
| Driver name: | Type 2 Licensed Driver: | ||||||
| ☐ | Yes | ☐ | No | ||||
| Destination: | ||||
| Purpose: |
| City and State | Event you are attending | ||||||
| Representing: | ☐ | Cascade High School | Event type: ☐ ASB (ASB advisor authority required) | |||||
| ☐ | Everett High School | ☐ | Athletics (athletics director authority required) | |
| ☐ | HM Jackson High School | ☐ | School (school principal authority required) | |
| ☐ | Sequoia High School | ☐ | District (district/department authority required) |
| ☐ | Other School Building | |||||
| ☐ | Other District Building | |||||
| EXAMPLE: |
| SUBTRACT | EQUALS | DIVIDE BY | EQUALS | ||||||||||
| 25,532 | - | 24,975 | = | 557 | / | 32.7 | ||||||
| = 17.03 |
| Ending mileage | Starting mileage | Miles driven | ||||||||||
| Gallons purchased MPG |
| ENTER YOUR INFORMATION HERE: | |||||||||||||
| SUBTRACT | EQUALS | DIVIDE BY | EQUALS | ||||||||||
| - | = | / | = | ||||||||||
| Ending mileage | Starting mileage | Miles driven | ||||||||||
| Gallons purchased MPG |
| Account Code: | Total fuel charge: $ | ||||
| Tape Receipt Here | ||||||
| (tape additional receipts to back of form) | ||||||
| Driver has: | ☐ | Refueled the vehicle to FULL | |||
| ☐ | Cleaned and removed debris from vehicle |
| Driver Signature: | ||||
| Budget Authority: | ||||
| ASB – Advisor | |||
| ATHLETICS – District Athletic Director | |||
| SCHOOL – School Building Principal | |||
| DISTRICT – Department Budget Authority | |||
| ASB Authorities: | |||
| ASB - Secretary | |||
| ASB - Student |
| ASB – Administrator |
| DISCLAIMER: Driver is responsible for the district gas credit card. Credit cards should never be left in district vehicles or attached to the keys. Credit cards should be stored in a secure place at all times. Keys should be returned to a secure and locked area. |