DRIVER AUTHORIZATION FORM I have read the “Minimum Standards for Driving” stated below. Initial Driver Authorization is required for employees, students, LTE’s, agents (may include collaborators on research projects) and employees whose job requires them to drive on university business. This includes using: • A State or university vehicle, • Any rented or leased vehicle while on university business, or • Personally-owned vehicle, if transporting other university employees or students. INSTRUCTIONS: 1. Read and completely fill out front of form. 2. Print legibly or type all information. 3. Obtain all the appropriate information and signatures before returning this form to the Welcome Center. CHECK ONE NAME Faculty/Staff Student Last LTE/Other First Middle M ____ DATE OF BIRTH MM/DD/YYYY F _____ SEX NUMBER OF YEARS DRIVING EXPERIENCE HOME ADDRESS WORK ADDRESS Street Address City State Zip Street Address City State Zip DEPARTMENT WORK PHONE NUMBER CELL PHONE NUMBER HOME PHONE NUMBER UWS EMAIL WORK EMAIL OTHER EMAIL DRIVERS LICENSE NO TYPE OF LICENSE Probationary STATE Regular EXPIRES CDL Other List All violations and describe all accidents for the past three years; if none, so state. IF OUT OF STATE LICENSE, THIS FORM MUST BE NOTORIZED (see next page) To the best of my knowledge, the above information is correct. I understand that my driving record will be checked by the university Risk Management designee. I further understand that any negative change in the status of my driver’s license may result in revocation of the privilege of driving a state-owned vehicle. I agree to notify my supervisor and the Risk Management designee immediately if my driver’s license becomes revoked, suspended or restricted. Driver’s Signature Date Department Chair or Supervisor Signature Date Department Chair or Supervisor Name Printed IF OUT-OF-STATE LICENSE, THIS FORM MUST BE NOTARIZED STATE OF WISCONSIN } } SS COUNTY OF DOUGLAS } being duly sworn states that the statements on this Driver Authorization Form are true to the best of his/her knowledge and belief. Subscribed and sworn before me on this day of , Driver’s Signature Notary Public, Douglas County, WI Commission Expires FOR OFFICE USE ONLY Approved for general fleet use or private auto on University Business (excluding vans) Approved for fleet van. Van course completed _. Date Approved for CDL required vehicles. Approved for on campus driving only. Denied: Frequency of violation and/or accident. Kind of violation, within the past 12 months. A temporary license. Had license less than two years. Giving false information on this form. Other Risk Manager or Designee Signature REVIEW DATES: (rev 11/11) 71-4400-41 Date EXPIRATION INFORMATION: Expiration of this authorization is one year from approval date for volunteers and the end of the semester for students. Expiration for faculty and staff is at the termination of employment. Wisconsin driving records will be reviewed every month in Fleet Anywhere and all others locally once per year. MINIMUM STANDARDS FOR DRIVING A STATE-OWNED-LEASED VEHICLE The Bureau of State Risk Management (BSRM) is charged with the responsibility of protecting the public and the state’s physical assets from loss. In a joint effort with the state agencies, the following minimum standards have been developed to provide state agencies and/or agency risk managers with guidance in applying sound risk management principles to the state vehicle usage. Agency management, in consultation with agency risk managers may consider extenuating circumstances as a reason to exempt a driver from these criteria. However, exemptions for extenuating circumstances should be documented and kept on file at the agency risk management office. If the agency does not have a risk manager, the request for exemption should be submitted from the Agency Secretary to BSRM for approval. Agencies should devise a method to reasonably assure that these standards and guidelines are followed. The following minimum standards are to be used by state agencies when employees/agents are driving state-owned or leased/rented vehicles on state business. An agency can operate under more stringent standards if it wishes. A state employee/agent may be allowed to drive a state-owned or leased/rented vehicle if all of the following minimum standards are met: 1. Must have a valid driver license, 2. Must have minimum of two years licensed driving experience, and 3. Must be eighteen (18) years of age. A state employee/agent may not drive a state-owned or leased/rented vehicle if their driving record reflects any of the following conditions: • Three or more moving violations and/or at-fault accidents in the past two years. • An OWI or DUI violation within the past year. (OWI/DUI violations are for operating while under the influence of an intoxicant, controlled substance or other drug.) Any exceptions to the above criteria should be approved by agency management, in consultation with agency risk managers, documented and kept on file at the agency risk management office. If the agency does not have a risk manager, the request for exception should be submitted from the Agency Secretary to BSRM for approval.
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