Admissions

Peace Officer: State Vehicle Use Agreement and Consent Form

Minnesota State Colleges and Universities
System Procedures
Chapter 5 – Administration
Consent Form associated with Guideline 5.19.3.1

Vehicle Use Agreement and Consent to Obtain Driving Record(s)
Effective September 1, 2009
The information you are being asked to provide on this page will be used by Minnesota State Colleges and Universities to determine your eligibility to drive state-owned or leased vehicles for system activities.

This information will be submitted to the state Department of Motor Vehicles for each state where you have held a driver’s license in the past five years. The driving record(s) obtained will be reviewed by the state Risk Management Division of the Department of Administration, which will rate the acceptability of your driving record. This rating will be maintained by the applicable system Human Resources Office and available to other system personnel including, but not limited to, your supervisor, who has a need to verify your eligibility to drive a state-owned or leased vehicle.

This consent form will be used to annually verify your driving eligibility unless you rescind your consent in accordance with the applicable campus or office procedure. You are not required by law to provide this information, but if you do not do so you will not be eligible to drive a state-owned or leased vehicle. If your job responsibilities require that you drive a state-owned or leased vehicle and you do not wish to complete this form, please discuss it with your supervisor. Your ability to drive a personal vehicle for system activities is not affected by your completion of this page. If you have any questions about this form or policy, please discuss them with your supervisor.

The submission and review process may take 7 to 10 working days. Effective 9/1/09, an employee’s driving record must be acceptable before reserving a state-owned or leased vehicle.

Complete and submit the following only if you authorize Minnesota State colleges and universities to obtain your Driver’s License Records to be eligible to drive a State owned or leased vehicle:

First name:*()**	First Name
Middle name:*()**
Last name:*()**	Last Name
Email:*()**
Birth Date: (mm/dd/yyyy):*()**	mm/dd/yyyy
Driver's License Number:*()**	Number from Driver's License card.
Issued by State of:*()**	State where Driver's License was issued.
Driver's License Class:*()**	e.g., Claas A, Class B, Class C
	Other Driver's Licenses held in last 5 years:
Name of State:
	Drivers' Responsibilities Driver agrees to: 1. Maintain an active, appropriate driver’s license; 2. Comply with Minnesota State Colleges and Universities’ Drivers’ License and Record Check Guideline 5.19.3.1 and other system policies and procedures applicable to travel; 3. Notify his/her supervisor immediately if driver’s license is suspended, revoked, cancelled, restricted or expired if driver intends to use state owned or leased vehicle; 4. Observe all posted speed limits and operate system vehicle in accordance with applicable laws and state regulations; 5. Avoid using cell phones, texting and/or other communication devices while driving; during system-related travel, use of cell phones is recommended only when the vehicle is stopped in a safe location. Vehicle Use Agreement My signature below signifies that I have read and understand the Driver’s Responsibilities noted above, and agree to abide by them. I AUTHORIZE THE MINNESOTA STATE COLLEGES AND UNIVERSITIES TO OBTAIN MY MOTOR VEHICLE RECORD (MVR) FROM ANY STATE WHERE I HAVE HELD A DRIVER’S LICENSE IN THE LAST FIVE YEARS BASED ON THE INFORMATION I HAVE PROVIDED ON THIS FORM FOR THIS PURPOSE. I AGREE THAT THIS CONSENT SHALL BE VALID FOR FIVE YEARS FROM THE DATE OF MY SIGNATURE UNLESS I RESCIND MY CONSENT IN ACCORDANCE WITH APPLICABLE PROCEDURES. I AGREE THAT THE INFORMATION I HAVE PROVIDED IS ACCURATE AND COMPLETE. If I intend to drive a state owned or leased vehicle, I agree to notify my supervisor immediately if the status of my driver’s license changes, as described above.
First name:*()**	First Name
Last name:*()**	Last Name
Today's date: mm/dd/yyyy *()**	mm/dd/yyyy

*indicates required

Minnesota West Peace Officer Program
Supervisor: Ronald Schwint
507-372-3405
ronald.schwint@mnwest.edu