ERRORS GO HERE HP Motor Vehicle Record - Authorization For Release of InformationAll individuals who will drive a university owned vehicle, university leased vehicle, rental vehicle for university business, who will drive on behalf of Stetson University to off campus locations on a regular basis, or who will transport students for university functions must present proof of a valid driver's license and an acceptable driving record as determined by the university's current auto insurance carrier.In order to obtain your motor vehicle record information, we request that you complete and sign this Authorization for Release of Information Form. This information is considered confidential and will be treated as such. The information obtained within your motor vehicle record is limited to our insurance agents, the Office of Human Resources, your current or potential supervisor, and your hiring administrator (if applicable).Only individuals with an acceptable driving record and a valid driver's license will be placed on the approved driver list. All approved drivers must adhere to the university's Vehicle/Driver Safety Policy & guidelines. Placement upon the approved driver list is only an indication of an acceptable driving record and does not provide automobile insurance coverage for personal vehicles used in performance of job responsibilities.Employees using their personal vehicle for business related travel should understand that their personal automobile insurance is always the primary insurance coverage. Individuals using their personal vehicle for business travel on behalf of the university on a 'regular basis' are those whose job assignment includes such travel, and who receive mileage reimbursement or a vehicle stipend which is intended to help offset the costs of fuel, wear-and-tear and personal automobile insurance coverage.Driver Information Driver's Name Driver's Date of Birth Driver's SUID Driver's License Number Driver's License State of Issue Has this drivers license been valid for five years? Select Option Yes No Previous driver's license number and state of issue. Driver's Phone Number Driver's Email Address Driver's Position Title University Department Departmental Contact/Supervisor Have you had one or more of the following violations in the previous five years? (Please select all that apply) Driving under the influence of alcohol or drugs Driving with an open container (alcohol) Reckless / careless driving Speeding in excess of 14 mph over the speed limit Hit and run Eluding a police officer Driving with a suspended / revoked license Vehicular assault, manslaughter, or homicide Operating a vehicle without the owner's permission Speed contest / racing Use of a vehicle to commit a felony Passing a stopped school bus None of the Above Have you had two or more of the following violations in the previous three years? (Please select all that apply) All other speeding violations Distracted driving (texting, calling, etc.) Improper lane changes Failure to yield At-fault accidents Tailgating Running a stop sign or red light None of the Above Driver's Home Address Street 1 Street 2 City State/Province ZIP/Postal Code Country Picture of Drivers Licence SignatureI certify that the information presented above is true and correct to the best of my knowledge. I authorize Stetson University, Inc. and its agent(s) to obtain my Motor Vehicle / Driving Record information for the purpose of determining eligibility for driving on behalf of Stetson in conjunction with employment duties or related university travel, and/or for approval to drive a Stetson leased, owned or rented vehicle. This information shall remain on file and shall serve as ongoing authorization for any future MVR screens. SignatureDate Submit
