Driver Authorization &Vehicle Use Agreement
Fill out, sign and return to Safety & Risk Management Office, University Services, Room 130.
Instructions:
____ If you are a Wisconsin Driver………………………………………………...............Complete Section A
____ If you are a Wisconsin Driver and have less than 2 years driving experience.. ..Complete Section A and Section B
_____ If you have an out-of state license……………………………………….....…..Complete Section A and Section B
Section A
Drivers Name:
-------------------------------------------
---Staff
Student
(Check whether staff or student)
Birth Date _____/___/19___
(Please Print)
Drivers License #: ____________________________________ State of: _________(Out of State or holding Wisconsin License less than 3
years must complete the bottom portion and have it notarized .)
Drivers License is:
Temporary ___
Probationary _____
Regular ____
List any violations and/or accidents, which have occurred in the past three years. If there are “none”, state there are
none.
___________________________________________________________________________________________________
_______________________________________________________________________________________________
A signature below signifies that all the above information is correct and I have received, read and understand my copy of the Fleet Policies
and Procedures Booklet which have been given. I have a valid & current drivers license.
Signature of Driver:
Business Phone:
Department Requesting Driver
Date
Building/Room
Section B
If you hold an out-of-state license, you much complete this portion
(Please note: you must sign this portion “in the presence of the Notary”)
This is to certify that I _____________________________________________________________ presently hold a valid driver's license from the
state/country of _______and that the accidents and violations listed on the reverse side are accurate.
___________________
(Date)
_______________________________________________________________________
(Signature) (only in presence of the Notary)
Subscribed and sworn to before me this _______ __________day
of _________________________________________, 20____________
My commission expires __________________________________________
(SEAL)
__________________________________________________________
(Notary Signature)
Risk Management----Office Use Only
Date:
Signature of Risk Management Office
( signed copy of Driver Authorization will be sent back to driver’s department which indicates approval)
O:\McNair Program\McNair Program\Handbooks\Scholar Handbook\APPENDIX A2--DRIVER AUTHORIZATION.docx
Due to the fact that you have an out-of-state/country driver's license we need you to complete this form.
NOTARIZED STATEMENT OF DRIVING RECORD
I have had a valid drivers license for two or more years? _______ yes _______no.
I have been ticketed for the following moving violations (if none, please enter "None"):
____________________
_______________________________________
____________________
_______________________________________
____________________
_______________________________________
Date /Offense
Describe Offense
I have been involved in the following accidents (if none, please enter "None"); if you have been involved in any accidents within the
past three years, please give a brief description of the accident(s) and whether you received a citation for these:
____________________
______________________________________
____________________
______________________________________
____________________
_____________________________________
Date/Accident
Describe Accident
This is to certify that I ___________________________________ presently hold a valid drivers license from the State/Country of
________________ and that violations/accidents listed above are accurate.
______________________
_________________________________
(Date)
(Signature of Driver)
Subscribed and sworn to before me this _______day
of ________________________, 20______________
My commission expires _______________________
____________________________________________
(Notary Signature) (SEAL)
O:\McNair Program\McNair Program\Handbooks\Scholar Handbook\APPENDIX A2--DRIVER AUTHORIZATION.docx