Employee Vehicle Use Acknowledgement

EMPLOYEE VEHICLE USE ACKNOWLEDGEMENT

Employee Name:   Employee ID:

Vehicle Use Authorization

This form documents authorization, conditions and responsibilities for use of company vehicles and/or employee personal vehicles used for company business. Employee must read and comply with all statements below and maintain required documentation with Human Resources or Fleet Administration.

Company vehicle assigned     Use of personal vehicle for business

Driver's License and Driving Record

Driver's License Number:   State of Issue:   Expiration Date:

Have you had any license suspensions, revocations or DUI/DWI convictions in the past 5 years? Yes

Insurance, Liability and Reimbursement

Employee certifies that liability and automobile physical damage insurance required by company policy and applicable law is maintained on personal vehicles used for business. Employee agrees to promptly notify employer of any change, cancellation or lapse of coverage.

Reimbursement for business use of personal vehicle (if applicable) will be in accordance with company policy and mileage records. Employee is responsible for maintaining accurate mileage logs and submitting them as required.

Authorized Use and Prohibited Uses

Authorized use of company vehicles or personal vehicles for company business is limited to official company duties. Use for personal errands, unauthorized passengers, or any commercial activity unrelated to company business is prohibited unless specifically approved in writing by the employee's manager.

Employee must comply with all traffic laws, related regulations, and company safety policies. Use of handheld mobile devices while driving is strictly prohibited except via hands-free operation consistent with company policy.

Accidents, Damage and Reporting

Employee must immediately report any accident, theft, damage, or citation arising from use of a company or personal vehicle on company business to local law enforcement (if required) and to the employer. Employee must cooperate in accident investigations and provide all requested documentation, including police reports, witness statements and insurance claim information.

Employee may be responsible for costs arising from negligent or unauthorized use, subject to applicable law and company policy.

Safety, Drug/Alcohol and Compliance

Employee must not operate any vehicle while under the influence of alcohol or controlled substances. Employee consents to any drug or alcohol testing required by company policy after an on-duty accident or where reasonable suspicion exists.

Seat belts are required for all occupants at all times. Employee will ensure all vehicle inspections, maintenance and service intervals are observed for company vehicles and will notify Fleet Administration of any mechanical issues immediately.

Driver's Motor Vehicle Record (MVR) and Authorization

By signing below, Employee expressly authorizes the employer to obtain and review motor vehicle records and driving history from state motor vehicle agencies and other appropriate sources at hire and periodically during employment to determine continued eligibility to operate company vehicles or use a personal vehicle for business.

Employee understands that unfavorable driving records may result in loss of driving privileges for company business and may lead to disciplinary action, up to and including termination.

Indemnity and Liability

To the extent permitted by law, Employee agrees to indemnify and hold company harmless from claims arising from the Employee's negligent or unlawful operation of a vehicle while performing company business, except to the extent that liability is imposed on the company by statute or contract.

Personal Information

Position Information

Employment History (Most Recent Employer)

Employment History (Prior Employer)

Education

Professional References

Legal Disclosures

At-Will Employment: Nothing in this vehicle use acknowledgement alters the at-will employment relationship unless explicitly stated in a separate written agreement signed by an authorized company representative.

Equal Opportunity: Employer is an equal opportunity employer. Employment decisions, including those affecting vehicle privileges, will be made without unlawful discrimination.

Applicant Certification and Authorization

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that false statements, omissions or misrepresentations may result in disciplinary action, including revocation of vehicle privileges or termination of employment.

I authorize the employer to contact prior employers and references listed above for verification of employment and to obtain motor vehicle records as described in this document. I authorize my insurer to release insurance information to the employer for verification purposes.

Consent to Background and Driving Record Check: I consent to background and motor vehicle record checks as necessary for assessment of driving privileges.

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