DRIVER STATUS - Pepperdine Community
Pepperdine DRIVER STATUS
University NOTIFICATION
FORM TO BE COMPLETED BY THE SUPERVISOR AND SIGNED BY BOTH SUPERVISOR & EMPLOYEE.
( New Driver (Please attach a photocopy of Driver’s License and Proof of Insurance)
( Other Status Change (complete employee name and all information that has changed)
GENERAL INFORMATION
|Last Name First | |
|Middle | |
| | |
|Date of Birth |Full Department Name (required) |
| | |
|Hire Date / / |Student Employee? ( Yes ( No |Termination Date / / |
|Please indicate if you would prefer to complete driver training in ( English or ( Español |
LICENSE INFORMATION
|Driver’s License Number |State |Class |Expiration Date |
| | | |/ / |
|Restrictions on License |
|Have you been involved in any auto accidents in the past three years? ( Yes ( No |
|Have you received any moving citations in the past three years? ( Yes ( No |
|If you answered yes to either of the above questions, please attach a description of the accident/citation. |
VEHICLE USE
|Frequency of vehicle use within the scope of employment. Mark ONE choice for each line. |
|University owned or rented vehicles: |( R ( P ( I ( N MARK (SUPERVISOR |
| |BOTH INITIALS) |
|Personally owned vehicle: |( R ( P ( I ( N LINES --------------------- |
| R - Regular use: weekly or more frequently |
| P - Periodic use: one or more times monthly |
| I - Incidental use: less than once a month |
| N - Not operated within the scope of employment |
|Will this driver be employed for more than 30 days within the next 12 months? |
| |
|( Yes ( No |
|Check the vehicle types that you have authorized this driver to operate within the scope of employment. |
|NOTE: The Supervisor is required by Vehicle Code to maintain this listing in their departmental files. |
|( Private passenger auto |( Bus - with air brakes _____ seating capacity |
|( Van - Utility |( Truck - to 1 ton |
|( Van - to 9 passenger |( Truck - 1 to 3 tons |
|( Van - to 15 passenger |( Forklift: ___ Gas ___ Electric Capacity ___ lbs. |
|( Bus - no air brakes _____ seating capacity |( Other (specify): |
If employee must have a CLASS B LICENSE for employment:
|License contains “Passenger Endorsement”? |Expiration date of Medical Certificate |
|( Yes ( No |/ / |
CERTIFICATION
|I have been advised and consent that: |
|(1) The University may obtain copies of my Driving Record directly from the DMV or other sources; |
|(2) In order to be permitted to drive a personal vehicle within the scope of employment on a Regular basis I must provide my |
|supervisor with proof that I carry auto liability insurance |
|(3) For the supervisor: Must this employee maintain an acceptable driving record as a condition of continued employment? |
|Please initial: YES_________ or NO_________ |
|Signature of EMPLOYEE |Date |
| |/ / |
|Signature of SUPERVISOR |Date |
| |/ / |
s:\fleet & drivers\driver status notification.doc RETURN TO Insurance & Risk Attention: JON WEBER
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- stock market status today
- sc driver license status check
- michigan driver s license status check
- first community bank 1 community place va
- mn driver s license status lookup
- check the status of my driver s license
- dps texas driver license driver records
- veteran status on driver s license
- mn driver s license renewal status check
- california driver license status check
- current driver s license status california
- check status of tn driver license online