University of Wisconsin-Parkside
Driver Authorization Form

SUBMIT TWO WEEKS PRIOR TO VEHICLE REQUEST.

Please Check One:

Permanent Employee         Student        
Limited Term Employee         Volunteer        

Name (Print)                                                                                                                              
                                  Last                                                      First                                    MI  
Driver's License Number State*
Department/Organization Years of Driving Experience
* Drivers who have a license from another state or country, or who have not had a Wisconsin license for the last 3 years, must also obtain a copy of their driving record to submit to Risk Management with the driver authorization.  Driving records can be obtained from the home state Department of Transportation.  Links to other states' Department of Transportation can be found in the "Minimum Standards" link or you may click here (http://www.fhwa.dot.gov/webstate.htm)

VEHICLE USE AGREEMENT

I acknowledge that I have read applicable sections of the "State of Wisconsin Fleet Driver and Management Policies and Procedures" Manual and understand them.
As a condition of my requesting and accepting driving privileges, I agree to a check of my driving record. I also understand that employee driving records will be checked annually and that student, volunteer, and some limited term employee driver authorizations expire on June 30th of each year.
I agree to inform my supervisor and University Risk Management immediately of any changes or updates in my driving record and if my driver's license is restricted, suspended, or revoked for any reason. I understand that any negative change in the status of my driving record may result in the revocation of the privilege of driving a state-owned vehicle.
NOTE: Individuals wishing to obtain 15 passenger van driver authorization must be at least 25 years of age.
                                                                          
Driver's Signature		                             
Phone		                    
Date
                                                                          
Director or Dean of Authorizing Department		                              
Phone		                    
Date
Driver is not authorized until Health and Safety/Risk Management approval is indicated below.
Risk Management Use Only Approved Yes No
                                                                           
Signature of Risk Manager		                       
Date		                             
Valid Through