15 Passenger Van by thebestone


									                                                                  15-Passenger Van
                                                           Driver Approval Form and Steps
                                                          Departmental Van In Town Use Only
     1)    Obtain 15-Passenger Van Driver Approval Form from your Supervisor.

     2)    Applicant and Supervisor complete the top portion of the form, including requested information in box area.

I attest that I have had a valid driver’s license for at least 1 year but not more than 3 years, not more than 1 moving violation, and no arrest or convections for DWI’s in
that time period and hereby give permission for Appalachian State University to perform a driving record check on said license. I am aware that it is my responsibility
to notify my supervisor of any DWI’s or moving violations I receive after this check is completed. Note: If applicable, indicate previous state(s) driver license

                          ____________________________________________                                            _________________________
                                     Applicant Signature                                                                    Date

     3)    Send completed form to University Police for driving record check via campus mail.
NOTE: Applicant must complete the driving record review prior to completing the Driver’s Awareness Course and the Driving Portion of the program!

Driver’s Name
As Appears on License __________________________________________________________________________ Date of Birth:__________________________
(Please Print)              Last                           First                    Middle

Current Driver’s License #: _____________________________                       Current Issuing State/# of Years Held _____________________________

Previous Driver’s License #: ____________________________                    Previous Issuing State/# of Years Held: ____________________________
NOTE: If you have been licensed in more than 2 states in the previous 3 years, attach additional information (issuing state/yrs, driver license #) to this form.

Hiring/Sponsoring Department:_________________________________________ Department Location (Bldg):_______________________________________

Department Phone #:_______________________                    Supervisor (Please Print):_____________________________________________________________

The prospective driver does   does not      meet all of the driver’s license requirements in order to operate a 15-passanger van within the city limits of Boone. If
applicable,   unable to complete out-of-state license record review due to state privacy information release guidelines. Contact University Police for more

                                                                                                                            University Police Initials/Date

     4)    Form will be returned to Sponsor Department’s Supervisor following the driving records check.

     5)    Applicant completes written portion of the Driver’s Awareness Course by either completing the on-line 15-passenger Van
           Awareness Course and Test or contacting HRS to enroll in the 15-Passenger Van Awareness Safety Training Program. Supervisor
           contacts Evan Rowe, Safety Director, for signature.

The prospective driver has      has not     completed the written portion of the Driver’s Awareness Course.
                                                                                                                               Trainer Initials/Date

     6)    Supervisor/Applicant contacts Bob Ellerbe, Motor Pool Director, to schedule and complete the driving portion of the course. Motor
           Pool Director signs the form and returns completed form to the sponsoring department’s Supervisor for record retention and

The prospective driver has      has not      completed the driving portion of the Driver’s Awareness Course or received a statement indicating he/she has been
“grandfathered” in.

                                                                                                                                 Trainer Initials/Date

                                          **All forms must be returned to the hiring department by way of inter-campus mail.
                             Contact the Safety & Workers’ Compensation Office at Extension 4007 if you have questions.

                       NOTE: TO BE PRINTED ON WAREHOUSE GOLDENROD PAPER                                                                    10/2005

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