DRIVER AUTHORIZATION FORM University of Wisconsin

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.