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Middlebury

 

Driver's License Application

MIDDLEBURY COLLEGE
DEPARTMENT OF PUBLIC SAFETY
COLLEGE VEHICLE DRIVER'S
APPLICATION
APPLICANT INFORMATION

Name of Applicant:  __________________________ Date of Application:_______College I.D._______
(Please Print)
State of Residence:  __________________________   State License #:  ______________________

Department/Sponsor:    ________________________Date of Birth ___________________________
(Students must have Dept. or Organiation signature)     
This application is for a:   (   ) new license     (   ) Revision

Have you ever been refused a license (or suspended) by Middlebury College?  _________________.

Have you ever been:   cited for DWI? ________,  cited for speeding in the past 3 years?  _______.  
involved in an auto accident?  ________.   License suspended? _________.
If you answered yes to any of these questions, provide details on separate sheet.

What license are you applying for?

Passenger car, mini-van, PU truck  (   )  Class 1

15-passenger van, Panel truck, Cube/Step van, flat bed truck  (  ) Class 2 Road orientation required

Handicapped van (  ) Class 2HCT    Towing  (   ) Class 2T  Road test required

I have read and understand Middlebury College 's policy on driving College owned and leased vehicles and I agree to abide by this policy as a condition of the license.  Furthermore, I agree to not to loan or permit anyone to drive a vehicle assigned to me if they do not possess a College license.   If for any reason my state license is suspended, I agree to surrender my College license to the Middlebury College Department of Public Safety immediately. I will also inform EH&S of any moving violations or DWI violations whether in my vehicle or a College vehicle.

_____________________________
Signature of Applicant

Department/Organization Sponsor:  ____________________________________________________
(Signature Required for Student initial Applications, not revisions)

I’ve had a valid driver’s license for over three years. ____________________________
(required for 15-pass, class 2)                                            (initial)

Applicant successfully completed defensive driver’s safety workshop on _________________
(not required for revisions)                                                              Date – EH&S initial

Applicant successfully completed ADA van required HCT training on  ____________________________
Date  -  DPS initial

Application :   (    ) Approved   (   ) Disapproved                Drivers test:  (  ) N/A   (  ) Passed   (  ) Failed

License
Approved by:  _________________________                       Date:  _____________________________
EH&S/DPS Officer

CONSENT AGREEMENT

*I agreed to allow Middlebury College to contact my state motor vehicle department for the purpose of verifying the information on my application.  I understand that this information will be kept confidential and that I may have access to this information.  Middlebury College reserves the right to conduct periodic driver record checks hereafter.

______________________________________                     ___________________________
(Please Print)                                                                         (Date)

______________________________________
Signature

Rev: 3/13