Driving History Any staff member or student who may drive an institution owned or leased vehicle or their personal vehicle on institution business should answer the following questions. Answer the Following 1. Do you have a current and valid state driver's license in the state where the institution is located?Please select... Yes No 2. Has your driver's license been suspended/revoked in the past five years?Please select... Yes No 3. Does your license have any restrictions?Please select... Yes No 4. Have you been convicted of driving under the influence in the last seven years?Please select... Yes No (If yes to questions 1-4, please explain at the bottom of this form.) 5. Have you been convicted of the following violations in the past three years? (Check, if yes)allowing unlicensed driver to operate vehiclecareless drivingdisregard a red light/stop signdriving 19 mph or underdriving on wrong side of roaddriving w/suspended/revoked licenseequipment violation/tires/lights/etc.failure to have vehicle under controlfailure to pat traffic ticketfailure to signal for direction/slowingfailure to stop for school busfailure to yield right-of-wayfleeing a police officerfollowing too closeimproper backingimproper enter/exit traffic wayimproper parkingimproper passing/lane change/useleaving the scene of an accident obstructed visionoperating unsafe vehicleoperating vehicle without insurancepassing through/around barrierracing on public highwayreckless driving/driving to endangerseat belt violationspeed in excess of 20 mph over limitspeed too great for conditions (If yes to any of these questions, please explain on second page of this form.) 6. Number of accidents involved in during the past three years: 7. Number of accidents in which you were at fault during the past three years: (Briefly describe the accidents at the end of this form.) 8. Are there any special accommodations you may require while driving a vehicle?Please select... Yes No 9. Are you 21 years of age or older?Please select... Yes No I certify that the information provided above is correct. Any discrepancy in the information found through an MVR check should result in the complete suspension of all driving privileges. I further understand that the information will be compared to establish criteria in determining my qualifications to drive on institution business. By checking this box:I agree and acknowledge the information above. Print Name Date Explanation for questions 1-4. Brief description for question 7. Contact Information
