STUDENT / VOLUNTEER / LTE DRIVER AUTHORIZATION FORM

STUDENT / VOLUNTEER / LTE DRIVER AUTHORIZATION FORM
I currently hold a valid driver's license. I understand that a copy of the Statewide Fleet Policies and Procedures is
available to download and read at: Fleet Driver and Management Policies and Procedures Manual I understand that
it is required and in my best interest to acquaint myself with these policies.
I understand that my driver information will be included in a statewide driver database that is checked monthly. Any
negative change in the status of my driving record may result in the revocation of the privilege of driving a state-owned
vehicle. I agree to inform my supervisor and the Office of Risk Management if there is a change in my driving status.
In addition, individuals with an out-of-state driver’s license, or, individuals holding a state of Wisconsin license
for less than three years due to previously being licensed in another state, must provide a copy of their official
state-issued driving record/abstract within 30 days of requesting driver authorization.
The driving record/abstract must accompany the Notarized Statement of Driving Record form. The notarized
statement must list any moving violations and/or describe accidents in the past three years. The form is found at:
http://www.uwex.edu/facilities/vehicle-authorization.html
This form should be returned to your Department Office when completed for review and signatures. Incomplete forms
will not be processed or returned. Please allow 10 days for processing. If approved, your name is added to the
approved driver database. Before driving or reserving a state vehicle, please verify driver is approved in the web site:
http://riskinfo.bussvc.wisc.edu/DrAuth/DriverAuth.aspx
Driver Name as it appears on license (Please Print Legibly):
Date of Birth:
Driver’s License Number:
Issue State/Country Full Name:
If Probationary, Issue Date:
Number of Years Driving Experience :
Email Address:
(exclude Temporary license/learners Permit)
Please Check Status Below:
Authorization Approval Length:
Student: _____ Volunteer:_____ LTE:_____
Whole Year:_____ Academic Year:_____ One Trip:_____
If applicant has a 12-15 Passenger Van Driver Card issued by the State
Have You Applied For Driver Authorization Before?
of WI Dept of Administration, please attach a copy to this application.
Reason that Applicant Needs Approval to Drive State Vehicles (Please Describe):
Signature of Applicant
Date Signed
Signature of Professor/Coordinator
Print Name
Date Signed
Signature of Department Chair/Director
Print Name
Date Signed
UNIT - DIVISION - DEPT CODE:
UWEX Division/Department:
Address:
T - ____ ____ - ____ ____ ____ ____
If Driver is denied, Contact Person for Notification (approvals are posted in the UW-Madison Risk Management Website see above):
Name:_________________________
Email:_______________________________________
Phone:_______________
Please keep original in Personnel File & email an attached copy to:
[email protected] or mail a copy to UWEX Risk Management, 109 Extension Bldg, 432 N.
Lake St., Madison, 53706.
UWEX Risk Management Revised 7/14