FM EHS/RM REV10302015
Personal Information
Full Name as it appears on Driver’s License: _______________________________________________________________.
Driver’s License State: ___________________. Driver’s License Nbr: __________________________________________.
Do you have State Minimum Liability Insurance for the vehicle being driven? Yes _____ or No ______.
I understand that my personal automobile insurance will be the primary form of insurance while
driving my personal vehicle on behalf of the University. Yes _____ or No_____.
Driving History
Drivers who have a high risk driving record will not have driving privileges on behalf of the University.
Do you have a high-risk driving record, i.e. including but not limited to the following: Yes _____ or No _____.
>>No more than three (3) moving violations in the past three (3) years
>>No more than one at-fault accident in the past three (3) years
>>Convicted of an OVI (Operating Vehicle Intoxicated)
Signature
Please print this form and sign it.
Scan it to the “Documents” section of your event registration form, if applicable.
I have completed this form below to the best of my knowledge.
Driving on behalf of the University, I give my permission for the University of Dayton to check my driver’s license
status, as needed, with the Bureau of Motor Vehicles.
Signature: ______________________________________________________________ Date: _______________________.
For office use only Date received: ______________________________________________________________________
Personal Vehicle Questionnaire
