TO BE COMPLETED ANNUALLY, UPON CHANGE OF STATE OF ISSUANCE, CLASS OF LICENSE, AND/OR DRIVING RESTRICTION CHANGE
Agency: ____________________________
Employee Name: _____________________ Employee Number: __________________________
Immediate Supervisor: _________________ Driver Training Course (MM/DD/YY):_____________
Drivers License Number: _______________ State of Issuance: ___________________________
AGENCY HEAD OR DESIGNEE AUTHORIZATION
By executing this document, I have reviewed the Official Driving Record and Driver Training Course dates and have confirmed the information to be current and in accordance with the ORM Loss Prevention requirements.
My signature authorizes the aforementioned employee to drive the following on state business as required (check all that apply):
_______ STATE VEHICLE
_______ RENTAL VEHICLE
_______ PERSONAL VEHICLE
______________________________ _________________________
AGENCY HEAD DATE OF AUTHORIZATION
(or designated individual)
EMPLOYEE ACKNOWLEDGEMENT/AUTHORIZATION
This is to certify that, as a condition of and if authorized to drive my personal vehicle on state business, I have and will maintain at least the minimum liability coverage as required by LA. R.S. 32:900 (B) (2).
I understand that the use of my vehicle on state business requires prior written authorization from my supervisor or agency head.
Further, by signing this document, I agree to notify my agency in writing should any of the following change on my license: Drivers License No., State of Issuance, Class of License or Driving Restrictions.
I authorize my agency to obtain access to my Official Driving Record (ODR) as necessary to comply with the State’s Loss Prevention Program.
I affirmatively acknowledge and understand that operating a state-owned, state-rented or state-leased vehicle while intoxicated as set forth in R.S. 14:98 and 14:98.1 is strictly prohibited, unauthorized, and expressly violates both the terms and conditions of my use of said vehicle, and my employer’s instructions. In the event such operation results in my being convicted of, pleading nolo contendere to, or pleading guilty to, driving while intoxicated under R.S. 14:98 or 14:98.1, I acknowledge and understand that such would constitute evidence of: (1) my violating the terms and conditions of my use of said vehicle, (2) my violating the direction of my employer, and (3) my acting beyond the course and scope of my employment with the State of Louisiana. I further affirmatively acknowledge and understand that personal use of a state-owned, state-rented or state-leased vehicle is not permitted.
My signature on this document shall remain in effect until revoked by the agency or until a new form is executed.
_______________________________ __________________________
EMPLOYEE SIGNATURE DATE
07/01/2012
DA 2054
07/01/2011
DA 2054
Supp.-1