Safety & Loss Prevention

Notarized Statement of Driving Record

NOTARIZED STATEMENT OF DRIVING RECORD *

This is to inform you that I presently hold a valid driver's license from the state/country of ____________ and that the following is a true statement of my driving record for the past three years. My drivers license expires on ___________. I have had a valid drivers license for two or more years? _______ yes _______no.

  1. I have been ticketed for the following moving violations (if none, please enter "None"):

    Date____________________          Offense________________________________










  2. I have been involved in the following accidents (if none, please enter "None"); if you have been involved in any accidents within the past three years, please give a brief description of the accident(s):










    _____________ _________________________________
    (Date)
    (Signature)

Subscribed and sworn to before me this _______day
of ________________________, 20______________
My commission expires _______________________
____________________________________________
(Notary Signature)                                    (SEAL)


* All UW System employees holding an out-of-state/country driver's license must complete this form in order to receive driving privileges on behalf of the University of Wisconsin System .