ÌÇÐÄvlog¹ÙÍø

Facilities Management

Application for Approved Driver List

Ìý

First Name: Ìý
Last Name: Ìý
ÌÇÐÄvlog¹ÙÍø ID: Ìý
Date of birth: Ìý
Department: Ìý
Position: Ìý
Email Address: Ìý
Phone Number: Ìý
Years driving experience: Ìý
Driver's License number: Ìý
Expiration date:
State issued: Ìý
Have you had experience driving a 15-passenger van? Ìý
Ìý
Check all that apply:
Ìý

If yes to any of the above, please explain.

Ìý		 Ìý Ìý
In the past 3 years, have you been convicted of the following:
Ìý

If yes to any of these questions, explain, including when and where.

Ìý		 ÌýÌý
Number of tickets or citations for moving violations in the last 3 years: Ìý

Explain the nature of these violations.

Ìý		 Ìý
Number of accidents during the past 3 years: Ìý

Briefly describe the accident(s).

Ìý		 Ìý
Number of accidents that you were at fault during the past 3 years:

Briefly describe the accident(s).

Ìý		 Ìý
Is there any reason you would not be able to drive aÌýmotor vehicle safely?
Ìý

Please explain.

Ìý		 ÌýÌý
Do any of your licenses have any physical or visual restrictions?
Ìý

Please explain.

Ìý		 Ìý

Ìý

ÌýBy checking this box, I agree that the above information is true and reflects my driving record over the past 3 years.Ìý If granted driving privileges, I will drive safely at all times and abide by College safe driving rules, including wearing my seat belt, while driving a College-owned vehicle or a rental vehicle on College business.Ìý By signing this application, I authorize ÌÇÐÄvlog¹ÙÍø College to request an MVR for the license listed above.Ìý IÌýwill alsoÌýabide by the following rules:

  1. All van drivers and passengers will be required to wear seat belts while traveling in the van.Ìý The responsibility for enforcing this rule lies with me, the driver.Ìý To promote enforcement, I have been notified that extension of the College's liability insurance coverage to myself, the driver, will only occur if all occupants are belted.
  2. I will not use a cell phone while driving, even if the phone is equipped with external speakers.
  3. I cannot drive more than 8 total hours in any 24-hour period.
  4. In the event of inclement weather, I, the van driver, will contact the Department of Public Safety for a ruling if or when the vans can be put on the road.Ìý If the State Police recommends that drivers not get on the roadways, the vans will not be authorized to travel.
  5. I will notify the Department of Public safety if any of the information I provided on this form has changed.
  6. I will complete the College's in-house van safety program conducted by theÌýDepartment of Public Safety prior to the operation ofÌýa van.