General Motors Corporation

General Motors Corporation

GM Safe Driving Program

Driver Acknowledgment Form

NOTE: Form is to be completed and sent to the GM Safe Driving Administrator at FAX number (248) 685-4425 (8-341-4425).

Driver’s Name (Exactly as printed on operator’s license):
LAST FIRST MIDDLE
/ Social Security Number:
______-____-______/ Operator’s License (Required):
Number: ______
State: ______
Expiration Year: ______

Type: ____ Operator

____ Chauffeur
____ Other
GM employing Unit / Unit Location / Phone Number (Required):
Date of Birth:
_____ - _____ - _____
(Month) (Day) (Year)
Contract House (If applicable):

DRIVER CONDUCT REQUIREMENTS

In order to drive GM-owned vehicles, driver must adhere to the following conditions:

1.  Possess a valid operator’s license and display such license upon request.

2.  Never drive while impaired by alcohol, drugs, medication, illness, fatigue, or injury.

3.  Ensure the proper use of safety belts and child safety restraints for all occupants.

4.  Obey all applicable motor vehicle laws, codes, and regulations.

5.  Drive in a defensive manner, anticipating situations where incidents are likely to occur.

6.  Refrain, at all times, from using radar/laser detection devices.

7.  Report all incidents/crashes involving damage to the vehicle, including reporting incident/crash to ESIS (a subsidiary of CIGNA Insurance) at 1-800-888-0154 and to the vehicle key issuer. (Direction is provided in the glove compartment of the vehicle.)

8.  Review the Safe Driving Program procedures and policies as outlined in the SDP handbook (NAO 0072) relative to the seven basics elements of the program as detailed. Adherence to the elements of the program will result in a safer driving environment for drivers of GM-owned vehicles and others who use the public roads.

DRIVER’S ACKNOWLEDGMENT: I verify that the above information is complete and accurate. I have read and understand the GM Safe Driving Program and agree to abide by the policy. I acknowledge that Motor Vehicle Record Checks (MVRCs) will be performed regarding my driving history. I understand that if I participate in the Senior Management Vehicle Program, Product Evaluation Program, Work-Related Travel Program, am a Quality Assurance Driver, or frequently use company-owned vehicles (e.g., pool vehicles), the completion of this form is required.

DRIVER’S SIGNATURE (Required): ______DATE (Required): ______

DRIVING RECORDS CRITERIA

As part of the GM Safe Driving Program, the following criteria have been established to evaluate drivers’ records.
Corrective actions will be taken where appropriate.
Level Corrective Action
I Driver education, possible suspension, Special Review Board action.
II Suspension from driving GM-owned vehicles*, Special Review Board action.
Action: Minimum Level
·  Violations of safety belt and/or child safety restraint use; failure to pay fine. Level I
·  Repeated violation of other motor vehicle laws (including speed limits). Level I
·  Driving while operator’s license is suspended, revoked, or denied. Level II
·  Vehicular manslaughter, negligent homicide, felonious driving or felony with a vehicle. Level II
·  Operating a vehicle while impaired, under the influence of alcohol or illegal drugs, or refusing
a sobriety test. Level II
·  Failure to stop or identify after a crash (includes leaving the scene of a crash; hit and run, giving false
information to a law enforcement officer). Level II
·  Eluding or attempting to elude a law enforcement officer. Level II
·  Traffic violation resulting in death, catastrophic injury, or serious injury. Level II
·  Any other significant violation warranting suspension of license. Level II
* Depending on circumstances and conditions, other actions may be taken up to and including termination of employment.

NAO-0041 (Revised 02/23/04)