Driver Acknowledgement Form

DNR SOP - AdminSOP030 Attachment #1

Driver Acknowledgement Form

Before operating a vehicle on department business, employees/volunteers/interns must use this form to certify that they are qualified to safely operate the vehicle. Employees/volunteers/internsthat drive on department business, regardless of the frequency, must use this form to recertify annually according to the schedule provided in the SOP.

By signing this form, I authorize the retrieval of my driving history and also certify that I am qualified to safely operate a vehicle for department business.

I am a (check the box that applies): DNR Employee Volunteer Intern

Please initial on each line.

I specifically certify the following:

I have a valid license for operating the vehicle. Expiration Date:

I agree to use vision correction measures while operating this vehicle, if required by my driver’s license.

I do not have pending charges, or a conviction within the past 6 months, for any ofthe following offenses, and I agree to immediately notify my supervisor should I be charged with one or more of these offenses:

• Driving Under the Influence
• Leaving the Scene of an Accident

I agree to notify my supervisor of any changes involving the above initialed items before I operate a vehicle for department business.

I agree to notify my supervisor immediately upon License Suspension, Revocation or Expiration.

I have reviewed and understand DNR SOP 030, Attachment # 2, Driver Safety Tips.

I have reviewed the driver safety video assigned for this year.

DRIVER’S LICENSE INFORMATION (please print and reflect information exactly as it appears on your driver’s license.)
First Name / Middle Name / Last Name / Date of Birth / License # / State

I have a valid out-of-state Driver’s license and have included a copy of my driver’s history with this acknowledgement form.

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Employee/Volunteer/Intern Signature Employee ID #

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Division Date

Page 1 of 1 1/2016