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