Barton County Community College, Great Bend, KS: Online Forms

Driver Authorization Form

Information Section

Please check one: Employee Student

Department or team, club, etc. you will be driving for:

Name as it appears on Driver's License:

First:

Middle Initial:

Last:

Driver's License #:

State of Issue:

Date of Birth (MM/DD/YY):

Phone number or e-mail address where you can be contacted:

Acknowledgement Section

As a condition of my being allowed driving privileges for college business, I agree to a check of my driving record and if approved, will abide by all of the College's travel procedures. I agree to inform my supervisor and the Office of Human Resources immediately of any changes or updates in my driving record and if my driver's license is restricted, suspended, or revoked for any reason. I understand that any negative change in the status of my driving record may result in the revocation of my privilege to drive for college business, possibly affecting my employment status with the College.

Driver's Signature: ______________________ Phone #:

Date:

Driver is not authorized until Office of Human Resources has indicated approval.

Return printed and signed form to: Office of Human Resources

Office of Human Resources Only Section
Approved: Yes No	Valid Through:
OHR Signature:	Date: