UW MADISON - STUDENT / VOLUNTEER / LTE DRIVER AUTHORIZATION FORM
DRIVER'S NAME AS IT APPEARS ON LICENSE (PLEASE PRINT):

BIRTH DATE:

DRIVER'S LICENSE NUMBER:

STATE/COUNTRY:

IF PROBATIONARY, ISSUE DATE:

TOTAL NUMBER OF YEARS DRIVING EXPERIENCE:

PLEASE CHECK ONE:

_____ STUDENT; _____ VOLUNTEER; _____ LTE 		SHOULD AUTHORIZATION BE APPROVED FOR:

___ WHOLE YEAR; ___ ACADEMIC YEAR; ___ONE TRIP
DO YOU HAVE A UW VAN DRIVER CARD AUTHORIZING YOU TO DRIVE 12-15 PASSENGER VANS?

HAVE YOU APPLIED FOR DRIVER AUTHORIZATION BEFORE?

IF ONE TRIP ONLY;
DATE OF DEPARTURE: __________________________ DATE OF RETURN:___________________________
PURPOSE FOR USING VEHICLE (PLEASE DESCRIBE):

Notarized Statements are required for:
A) Individuals holding out-of-state driver's licenses.
B) Individuals holding a Wisconsin Driver's License less than three years, due to previously being licensed in another state or country.

Statement must list any moving violations and/or describe accidents in the past three years. Also, please attach a copy of the driver's license if issued any where outside of Wisconsin.

Vehicle Agreement: I understand that a copy of the Statewide Fleet Policies and Procedures is available to download and read at http://www.bussvc.wisc.edu/risk_mgt/Fleet%20Driver%20and%20Mgmt%20Policies%202004%2011.pdf. I understand that it is in my best interest to acquaint myself with these policies. I understand that my driver information will be included in a state wide 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.
SIGNATURE OF VOLUNTEER/STUDENT/LTE:

DATE SIGNED:

SIGNATURE OF PROF/COORDINATOR MAKING REQUEST (PRINT NAME):

DATE SIGNED:

SIGNATURE OF DEPARTMENT CHAIR/DIRECTOR (PRINT NAME):


DEPARTMENT PHONE NUMBER:

DEPARTMENT NAME, ADDRESS AND E-MAIL ADDRESS: (PLEASE PRINT):


UNIT-DIVISION-DEPT-CODE: __A__ - ___ ___ - ___ ___ ___ ___
Send completed forms to: Risk Management, 720 University Ave (campus mail) or via fax number: 608-262-9082.

Incomplete forms will be returned. Please allow 10 days for processing. If approved, your name will be added to the database. Before driving or reserving a vehicle, check this web site: http://riskinfo.bussvc.wisc.edu/DrAuth/DriverAuth.aspx?%20. Originals are for department files.

Revised 11/05