Utica College
Application for College Driving Privileges
NAME:______________________________________________________ DATE: _______________
Last First Middle
Permanent Address: _______________________________________________________________________
St Number and Name City State Zip
Department/Campus Address:_______________________________________________________________
Home Phone #: __(_____)___________________ Work Phone #: __(______)___________________________
Name & Number of Emergency contacts: ________________________________________________________
Date of Birth: __________________ Years of driving experience ___________
Driver's license number: ________________ State of Issuance: _____________
Expiration Date: ______________ Class or type: _______________
Number of moving violations within last 3 yrs: _________
Type of moving violations: ___________________________________________________________________
I, _______________________________________, understand and agree to the following:
1. To the best of my knowledge, the information recorded on this application is correct. I understand that
any misrepresentation of falsification of information may be sufficient cause for rejection of motor vehicle
operating privileges.
2. I authorize Utica College and its authorized insurance representatives to inquire and verify the
information contained herein to include review of my motor vehicle record. This authorization shall be valid in
original, fax or copy form and shall serve as an ongoing authorization to procure MVR information on an
ongoing basis during my employment.
3. I agree to abide by all laws and regulations pertaining to the operation of motor vehicles, as well as,
College driving policy regulations.
4. I have the right, upon request, to a complete and accurate disclosure of the nature and scope of the report and
a copy of my Consumer’s Rights under the Fair Credit Reporting Act.
Signature of applicant:____________________________________________ Date:______________________