Certification of Prerequisites to Drive a University Van
Please complete this form and return to the Rowan EHS office with a copy of your Driver’s
license. This form and a copy of a valid driver’s license MUST be received by EHS before any
course completion will be considered valid.
I,__________________________________, certify that:
(Please Print)
a. I have at least two (2) years of driving experience.
b. My license is not currently suspended or revoked in any state.
c. I have not been issued more than three moving violations in the past thirty-six (36)
months.
d. I have not been issued more than two (2) moving violations in the past twelve (12)
months.
e. I have not been convicted of driving under the influence (DUI) of alcohol or drugs in
the past thirty-six (36) months.
f. I am at least 21 years old.
g. I have a valid state issued United States driver’s license (copy attached).
h. I will be completing this training myself.
The information I have provided above is true and accurate to the best of my knowledge and
belief. I understand that I may be subject to penalties if any of the above statements is found to
be false. Such penalties could include disciplinary action, up to and possibly including
termination of employment, as well as criminal and/or civil penalties.
Signature_________________________________________________
Date_____________________________________________________