STATE OF L
OUISIANA
DRIVER
AUTHORIZATION
FORM
TO BE COMPLETED ANNUALLY, UPON CHANGE OF STATE OF ISSUANCE, CLASS OF LICENSE, AND/OR DRIVING
RESTRICTION CHANGE. OR TO GO FROM UNAUTHORIZED TO AUTHORIZED STATUS.
Employee Name: Campus ID Number:
Driver’s License Number: Driver Training Course (MM/DD/YY): ______________________
Driver’s License State: Immediate Supervisor: _____ __
Agency:
NORTHWESTERN STATE UNIVERSITY
Department: _
____________________________________
___FACULTY ___STAFF ___GRADUATE ASSISTANT ___STUDENT WORKER ___OTHER _________________
DO NOT SIGN IN THIS AREA.
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
A
GENCY HEAD DATE OF AUTHORIZATION
(or designated individual)
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:
Driver’s 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, each year I am employed with the Agency.
I affirmatively acknowledge and understand that operating 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 signature on this document shall remain in effect until revoked by the agency or until a new form is executed.
I have received a copy of the Northwestern State University Driver Safety Policy.
E
MPLOYEE SIGNATURE DATE
07/01/2012
DA 2054
