_______
Agency:
____________________________
Employee Name:
_____________________
Employee Number:
__________________________
Immediate Supervi
sor:
_________________
_____________
Drivers License Number:
(MM/DD/YY):
_______________
State of Issuance:
___________________________
_______
_______
___________________
___________ _________________________
A
GENCY HEAD DATE OF AUTHORIZATION
(or designated individual)
_______________________________ __________________________
EMPLOYEE SIGNATURE DATE
Driver Training Course
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
S
TATE OF LOUISIANA
DRIVER AUTHORIZATION FORM
TO BE COMPLETED ANNUALLY, UPON CHANGE OF STATE OF ISSUANCE, CLASS OF LICENSE, AND/OR DRIVING
RESTRICTION
CHANGE
AGENCY HEAD OR DESIGNEE AUTHORIZATION
By executing this document, I have reviewed the Official Driving Record and Driver Training Course dates and have
confirmed the information to be current and in accordance with the ORM Loss Prevention requirements.
My signature authorizes the aforementioned employee to drive the following on state business as required (check all that
apply):
STATE VEHICLE
RENTAL VEHICLE
PERSONAL VEHICLE
EMPLOYEE ACKNOWLEDGEMENT/AUTHORIZATION
This is to certify that, as a condition of and if authorized to drive my personal vehicle on state business, I have and will
maintain at least the minimum liability coverage as required by LA. R.S. 32:900 (B) (2).
I understand that the use of my vehicle on state business requires prior written authorization from my supervisor or
agency head.
Further, by signing this document, I agree to notify my agency in writing should any of the following change on my license:
Drivers License No., State of Issuance, Class of License or Driving Restrictions.
I authorize my agency to obtain access to my Official Driving Record (ODR) as necessary to comply with the State’s Loss
Prevention Program.
I affirmatively acknowledge and understand that ope
rating a state-owned, state-rented or state-leased vehicle while
intoxicated as set forth in R.S. 14:98 and 14:98.1 is strictly prohibited, unauthorized, and expressly violates both the
terms and conditions of my use of said vehicle, and my employer’s instructions. In the event such operation results in
my being convicted of, pleading nolo contendere to, or pleading guilty to, driving while intoxicated under R.S. 14:98 or
14:98.1, I acknowledge and understand that such would constitute evidence of: (1) my violating the terms and
conditions of my use of said vehicle, (2) my violating the direction of my employer, and (3) my acting beyond the
course and scope of my employment with the State of Louisiana. I further affirmatively acknowledge and understand
that personal use of a state-owned, state-rented or state-leased vehicle is not permitted.
My signatur
e on this do
cument shall remain in effect until revoked by the agency or until a new form is executed.
07/01/2012
DA 2054
