Request For Use Of State Aircraft Form
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1REQUEST FOR USE OF STATE AIRCRAFT
SECTION I - AGENCY INFORMATION
REQUESTING AGENCY:______________________________________________________________________
CONTACT PERSON:______________________________________ DATE:______________________________
PHONE #:_____________________________________FAX #:________________________________________
SECTION II - FLIGHT INFORMATION
FLIGHT SCHEDULE
LEG
DATE
DEPART
CITY
STATE
ARRIVAL
CITY
STATE
# / PASS.
TIME
TIME
1.
2.
3.
4.
5.
6.
IS CATERING REQUESTED, IF SO, WHICH LEG? ______________________________________________
PURPOSE OF TRIP (BE SPECIFIC):_______________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
NAMES OF PASSENGERS:
___________________________________________ ________________________________________________
___________________________________________ ________________________________________________
___________________________________________ ________________________________________________
___________________________________________ ________________________________________________
SEC. III-PUBLIC OFFICIAL/AGENCY HEAD AUTHORIZATION AND RESPONSIBILITY STATEMENT
I attest that the above stated request for air service by myself or this agency is in accordance of state laws and policies
set forth by the Department of Finance and Administration. I have determined that using the state aircraft is economically
more feasible or otherwise justifiable than other alternatives. I agree to keep records on file at my agency for review
by the State Auditor regarding the flight. I further understand that misuse of state aircraft can result in my reimbursing
the State of Mississippi for the actual expense associated with this flight, in addition to a possible fine, upon conviction,
not to exceed $500. (Sec. 61-13-19, Miss. Code 1972 Annotated)
___________________________________________
Public Official or Agency Head
_________________________
Date
AIR TRANSPORT ONLY
DATE REQUEST RECEIVED:_________________________
REQUEST APPROVED BY:___________________________
DATE OF APPROVAL:_______________________________
MAIL COMPLETED/SIGNED FORM TO: Office of Air Transport Services,
FLIGHT APPROVAL #:______________________________
P.O. Box 98146, Jackson, MS 39298 or
FAX TO: Office of Air Transport Services, (601) 932-2989.
September 17, 1999
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