DEPARTMENT OF PUBLIC SAFETY
COLLEGE VEHICLE DRIVER'S
Name of Applicant: __________________________ Date of Application:_______College I.D._______
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
Approved by: _________________________ Date: _____________________________
*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)