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DEPARTMENTAL VEHICLE CHECK-OUT FORM

Department Name: Vehicle Number:

My signature below acknowledges that I have read and understand the information in the University policy “Use of Vehicles for University Business” and agree to abide by all the obligations and requirements therein. Further, I have self-evaluated based on the chart shown on the reverse side of this form, and hereby certify that I fall within the “Acceptable” category as defined in the chart. I understand that knowingly operating a University Vehicle while not meeting the minimum driver qualifications may result in disciplinary action, and may void any protections I might otherwise enjoy under University policies.

Driver Name (printed)

Driver Signature

Purpose for use

Date/Time

Date/Time

Taken

Returned

Note: Departments should retain this record for at least 24 months following the last date recorded on this form.

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