Fillable UA DRIVER AUTHORIZATION (Kenai Peninsula College)

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UA DRIVER AUTHORIZATION (Kenai Peninsula College)

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University of Alaska 06/16/2011
Transportation Safety Guide
Rev 2
14
Risk Management Team
www.alaska.edu/risksafety
UA DRIVER AUTHORIZATION
(Category 1 Drivers)
Page 1 of 2
This form is to be completed at least annually for individuals for whom any of the following apply:
Driving on UA business is required by the official job description
A UA vehicle has been assigned for their use
Where a CDL license is required for UA work
Drivers who will be required to drive for a period exceeding 14 (fourteen) consecutive days
For long distance travel (greater than 50 miles one way)
Drivers who will transport groups, students, minors, and/or other non-UA affiliated persons
DRIVER
To complete this section
Name:
Date of Birth:
Drivers’ License #:
Drivers’ License Expiration Date:
Attach a copy of driver’s license (probationary, court restricted, international drivers’ license or a drivers’ permit
are NOT acceptable)
Attach a copy of UA drivers’ safety training course completion documentation
I certify I am in compliance with all licensing and insurance requirements for the State of Alaska. I agree to notify my
supervisor, by the next working day, of any changes to my compliance status, any moving violations I may receive, and
to IMMEDIATELY notify my supervisor of any accidents.
I have read and understand the information included in the Transportation Safety Guide. I understand the university's
insurance for its vehicles is effective only when the vehicle is being used for authorized university business purposes by
an authorized driver. I understand the transportation of passengers who are not University of Alaska employees should
first be cleared by my supervisor and the university does not carry insurance for non-employee passengers.
Name (printed):
Signature: Date:
Appendix A
University of Alaska 06/16/2011
Transportation Safety Guide
Rev 2
15
Risk Management Team
www.alaska.edu/risksafety
UA DRIVER AUTHORIZATION
(Category 1 Drivers)
Page 2 of 2
SUPERVISOR
To complete this section
TRUE
1.
Driver has attached all of the above required documents
2.
I have obtained and reviewed a copy of the driving record report from the state department of motor
vehicles
3.
Driver has at least three (3) years of driving experience
4.
If transporting groups, students, minors, and/or other non-UA affiliated persons, driver is age 21
or older
OR
This item is Not Applicable
5.
If driver is not age 21 or older, he/she is not going to transport groups, students, minors, and/or other
non-UA affiliated persons
6.
Driver has not been convicted for two or more moving violations in the last three years
7.
Driver has not been convicted, or had his/her license revoked, for driving under the influence of
alcohol or drugs in the last three years
8.
Driver does not have a pattern of moving violations or reckless driving behavior which is
demonstrated by the accumulation of more than five points against his/her drivers’ license in the last
three years
9.
Driver has been given the a copy of, or web access to, the UA Transportation Safety Guide and asked
to read it
If you are unable to check any of the above boxes, please contact your campus risk management/environmental
health and safety department for assistance prior to authorizing UA driving responsibilities. Only individuals
who have been properly screened prior to beginning work, (including a pre-hire review of driving record, if
applicable), should be allowed to operate a vehicle on UA business. Contact your campus risk
management/environmental health and safety office for non-affiliated or student driver requirements.
SUPERVISOR’S APPROVAL TO DRIVE
YES NO
Supervisor Name (printed):
Supervisor Signature: Date:
Comments:
University of Alaska 06/16/2011
Transportation Safety Guide
Rev 2
16
Risk Management Team
www.alaska.edu/risksafety
UA OCCASIONAL DRIVERS’ AFFIDAVIT
(Category 2 Drivers)
This affidavit is to be completed for individuals for whom driving on UA business is required on an occasional basis.
This form should be completed at least annually. This form is NOT to be used by individuals for whom driving on UA
business is a requirement of their official job description, who have a vehicle assigned for their use, who are required to
carry a CDL license, for a driving assignment exceeding 14 (fourteen) days, for long distance travel (greater than 50 miles
one way), or for drivers who will transport groups, students, minors, or non-UA affiliated passengers. Those drivers
should use the Category 1 Driver Authorization form.
I, ____________________________________________________, ____________________, have been requested by the
(print name) (work phone number)
________________________________________ department to be a vehicle driver for activities necessary to departmental
operations for the period from:____________________ to: ____________________. I understand my driving record
affects my authorization to drive a vehicle on UA business.
Driver's License Number:
State (if other than Alaska):
Expiration Date:
TRUE
1.
I possess a current and valid drivers’ license.
2.
I am in compliance with all licensing requirements for the State of Alaska and my license is not
probationary, court restricted, international nor is it a drivers’ permit.
3.
I am in compliance with the mandatory state liability insurance requirement for the vehicle I will be
driving.
4.
I have at least three (3) years of driving experience as a licensed driver.
5.
I have not been convicted for two or more moving violations in the last three years.
6.
I have not been at fault in two or more accidents in the last three years.
7.
I have not been convicted, or had my license revoked, for driving under the influence of alcohol or drugs in
the last three years.
8.
I do not have a pattern of moving violations or reckless driving behavior which is demonstrated by the
accumulation of more than five points against my drivers’ license in the last three years.
Explain any NOT TRUE responses here:
I certify the foregoing information is true and accurate. I agree to notify my supervisor, by the next working day, of any changes to
my above certifications, any moving violations I may receive and to IMMEDIATELY notify my supervisor of any accidents. I
understand the university's insurance for its vehicles is effective only when the vehicle is being used for authorized university business
purposes by an authorized driver. I understand the transportation of passengers who are not University of Alaska employees should
first be cleared by my supervisor and the university does not carry insurance for non-employee passengers.
______________________________________________________ __________________________________________
Driver Signature Date
SUPERVISOR’S APPROVAL TO DRIVE YES NO
Supervisor Name (printed):
Supervisor Signature:
Date:
Comments:
Appendix B
✔
✔
✔
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Completed 10 October 2020

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