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Motor Vehicle Policy Acknowledgment and Record Certification

I certify that my Motor Vehicle Record does not include any of the conditions listed below that could prevent me from being eligible to drive a college vehicle, and I agree and acknowledge that the College may, at its discretion, request and review a copy of my MVR to confirm the accuracy of this certification.

  • More than two (2) minor accidents (any event which results in damage to vehicle and property, or injury to a person, with damages of less than
    $2,500), for which you are at fault, in the past five (5) years.
  • Any major accident (any event which results in damage to a vehicle or property, or injury to a person, with damages exceeding $5,000), for which you are at fault, in the past five (5) years.
  • Recorded instance of driving on a suspended license, or for failure to appear in court, within the past five (5) years.
  • Conviction for reckless driving within the past five (5) years.
  • Conviction for alcohol and/or related driving offense within the past five (5) years.

I have read and understand the stipulations regarding the use of College vehicles and I agree to abide by these policies and regulations.

"*" indicates required fields

Employee Information

Select the employee's originating department. A record of this certification will be sent to the department administrator.
Name*
MM slash DD slash YYYY

Drivers License Information

MM slash DD slash YYYY

Related Links:

Eligibility to Drive a College Vehicle