Authorization and Driving History Form
The following information will be retained on file by all agencies on their drivers authorized to operate a
State vehicle, or a private vehicle for state purposes:
Name ____________________________________________ Drivers License No. _______________________
Date of Birth ______________________________________ Issuing State _________ Class License _______
Phone Number: (______) - ___________________ Issue Date _______________________________
LSU Employee ID No._______________________________ Expiration Date ___________________________
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Department employed by ______________________________ Department Code (first 5 digits)______________
Dept Address _________________________________________________________________________________
Job Title ___________________________________________ Position: Staff_____ Faculty_____ Student_____
Is employee’s primary purpose to drive vehicles? Yes_____ No_____ (A YES answer requires a license class other
than Class E.)
Is driver authorized to operate his/her private vehicle in the course and scope of employment? Yes_____ No_____
Date of last Driver Training Course? _____/_____/_____ (mm/dd/yy)
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State vehicle(s) authorized to operate:
Any LSU State Vehicle VEH #1 VEH #2 VEH #3
Type of Vehicle __________________ ___________ ____________ ___________
Date Trained _____________ _____ ___________ ____________ ___________
Source of Training __________________ ___________ ____________ ___________
_____________________________ _________________________ _________________ ____________
Supervisor's Printed Name Supervisor's Signature Phone Number Date
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I understand that I must report any accident while performing state business to my supervisor as soon as possible,
and complete a “Driver’s Accident Report Form” (DA 2041) within 48 hours. I also understand that I am
responsible for reporting any citations I receive, and to pay any traffic fines levied as a result of the citations.
I certify that if I am 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 also understand that the use of my vehicle on
state business requires: 1) prior written authorization from my supervisor or agency head, 2) a current liability
policy meeting the requirements of LA R.S. 32:900(B)(2); and 3) my paying of all expenses I have as a result of
using my vehicle, subject to receiving at a later date the reimbursement pursuant to the State's travel policy. I
understand that any false statement on this form or failure to notify my supervisors of any change in my insurance
status could result in disciplinary action.
___________________________________________ ___________________________
Employee Signature Date
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AGENCY HEAD OR DESIGNEE STATEMENT
I have reviewed this individual’s genuine need to drive a State Vehicle, and/or to drive his/her personal vehicle on
state business. In conducting this review, I have considered his/her driving experience, and type of vehicle to be
operated. I authorize this individual to operate the vehicles approved by the type of license above. The individual is
aware of the requirement to report any accident while performing state business to his/her supervisor as soon as
possible and to complete a “Driver’s Accident Report Form” (DA 2041) within 48 hours of the accident. This
authorization must be reviewed one year from this date.
_________________________________ _______________________________ ____________________
Agency Head (or Designated Authority) Agency Head Signature Date of Authorization
Return this form to: Office of Property Management, River Road Annex Building, 3555 River Road
The attached operator’s record has been verified as accurate and dated as necessary. _____________________
Property Management
DA 2054-LSU rev 8/14/12
