Safety & Loss Prevention

Student or Volunteer Driver Authorization Form

 

 

 

 

 

Original ___ Update ___ Employee: ______ Student ____ Volunteer _____

(check all that apply)

 

Vehicle Use Agreement

Driver's Full Name (include middle initial)

Driver's License No.

 

State (if not WI)

 

 

Driver's Complete Worksite Mailing Address

 

 

Work County :

Driver's Date of Birth (mm/dd/ccyy)

 

Full Agency or Department Name

UW SYSTEM ADMINISTRATION

Division or Campus

 

 

Driver's email address (if none, provide supervisor's)

 

 

Work Phone Number

 

Instructions:

All state/university employees driving a state-owned vehicle must complete this form or an equivalent agency form.

 

Employees who choose not to sign this agreement may use their personal vehicle for state business, if authorized by their agency. Mileage reimbursement will be at a rate established annually by the Department of Administration.

 

Completed forms are to be returned to the employee's immediate supervisor, then signed and promptly forwarded to the Owner Agency at the address above.

 

If any information provided on this form should change, it is the employee's responsibility to complete a new form.

 

Processing time is two to four weeks. State vehicles may not be driven until you are notified of approval.

 

Employee Agreement:

I acknowledge that I have received and/or read a copy of the statewide Fleet Driver and Management Policies (DOA-3068P; available at: http://www.doa.state.wi.us/docs_view2.asp?docid=2477 ). I understand the contents and agree to comply with the policies. Failure to comply is considered a violation of work rules.

 

I further agree to inform my supervisor whenever any negative change in the status of my driving record may occur, such as license revocation, restriction or suspension. I understand that any negative change in the status of my driving record or the failure to report such change may result in the revocation of the privilege of driving a state-owned vehicle.

 

Driver's Signature

Date (mm/dd/ccyy)

 

Supervisor's Signature

Date (mm/dd/ccyy)

 

Supervisor's Name (please print or type)

E-mail address

 

Fleet Coordinator Signature __Approved __Denied

Owner Agency Approval __Approved __Denied