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Mark Twain Union ESD |  E  3512.1  Business and Noninstructional Operations

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Mark Twain Union Elementary School District

Request for Approved Driver Status

This form should be properly completed and signed as appropriate. Submission to the District Office must be made at least one week prior to driving a District vehicle.

In connection with my application for Approved Driver status with the School District, I understand that prior to or at any time after my acceptance as an Approved Driver, a Motor Vehicle report may be requested from the public records to the extent permitted by law from various local, state and federal agencies.

I VOLUNTARILY AND KNOWINGLY AUTHORIZE ANY LAW ENFORCEMENT AGENCY, STATE AGENCY, LOCAL AGENCY, FEDERAL AGENCY, AND/OR OTHER PERSONS TO GIVE RECORDS OR INFORMATION THEY MAY HAVE CONCERNING MY MOTOR VEHICLE HISTORY.

I understand that I have the right to request a complete and accurate disclosure of the nature and scope of the investigation requested. Further, I am entitled to know if my application for Approved Driver is denied because of information obtained. If so, I will be so advised and be given the name and address of the agency, a statement that the action was based in whole or in part on information contained in the report and written notice that I have the right to dispute the accuracy or completeness of any information in the Motor Vehicle report furnished. I understand that upon my written request with reasonable notice the School District will supply me with a copy of the Motor Vehicle Report as permitted by law.

I understand that I must authorize procurement of such report(s). A photographic or faxed copy of the Notification and Release Authorization shall be as valid as the original. In addition, my signature acknowledges that I have read and understand the School District's Transportation Policy.

Applicant's Signature Date

PLEASE PRINT OR TYPE THE INFORMATION REQUESTED BELOW:

Name (as it appears on your license):

Mailing address:

Driver's License #: State of Issuance:

License Expiration Date: Date of Birth:

Request for Approved Driver Status (continued)

Driving privileges will not be granted to individuals whose driving record indicates one or more of the items noted below:

1. Three or more speeding tickets during the past three years

2. Speed in excess of 25 mph over the posted limit during the past three years

3. Two preventable accidents in a 12 month period during the past three years

4. Operating during a period of suspension or revocation during the past five years

5. Operating a motor vehicle without the owner's authority during the past five years

6. Reckless driving during the past five years

7. Failure to report an accident or a hit and run accident during the past five years

8. Negligent homicide arising out of the use of a motor vehicle

9. Cited for driving while under the influence of alcohol or drugs (DWI/DUI) during the past five years

10. Permitting an unlicensed person to drive

11. Using a motor vehicle for the commission of a felony during any time period

12. Possession of illegal substances or illegally possessing any weapon(s) within the past five years

DISTRICT OFFICE USE ONLY:

Authorized

NOT Authorized

Exhibit MARK TWAIN UNION ELEMENTARY SCHOOL DISTRICT

version: April 09, 2015 Angels Camp, California

___________________________________________________________________________

Exhibit (2)

USE OF PRIVATE VEHICLE REQUEST FORM

DRIVER INFORMATION: (please print)

Name:

Address:

Street City State Zip Code

Driver's License Number: / Date of Birth:

Number State Month / Day / Year

Driver's License Expiration Date: Day Year

Please attach a current copy of Driver's License.

VEHICLE INFORMATION: (please print)

Make: Model: Year:

Vehicle License Number:

Registered Owner: Phone Number: ( )

Address:

Street City State Zip Code

INSURANCE INFORMATION: (please print) Please attach a current copy of your Auto Liability ID card

Insurance Carrier:

Insurance Agent: Phone Number: ( )

Address:

Street City State Zip Code

Limits of

Policy Number: Expiration Date: Liability:

I certify that the information given on this form is true and correct to the best of my knowledge. I understand that as a volunteer driver or district employee, I must possess a valid and current driver's license that is designated for the class of vehicle to be driven, a current vehicle registration and have at least the minimum insurance coverage in effect as specified in the California Vehicle Code on any private vehicle I use to transport students or for District business. I hereby certify that the vehicle being driven is in good mechanical and operational condition and I have no knowledge of mechanical defects that could impose a danger while transporting students. I understand that, per the California Vehicle Code, my personal automobile liability insurance policy shall be primary in the event of an accident and I understand that the District provides no insurance coverage (comprehensive or collision) for physical damage to my personal vehicle.

I give my permission to allow the Mark Twain Union School District to obtain my motor vehicle record from the Department of Motor Vehicles.

Signature: Date:

Please Print Name:

Exhibit MARK TWAIN UNION ELEMENTARY SCHOOL DISTRICT

version: April 09, 2015 Angels Camp, California

___________________________________________________________________________

Exhibit (3)

REFER TO DISTRICT OFFICE FOR EXHIBIT E(3) 3512.1

DRIVERS LICENSE INQUIRY/EMPLOYER PULL NOTICE STATUS & RECORD REQUEST FOR INFORMATION

Exhibit MARK TWAIN UNION ELEMENTARY SCHOOL DISTRICT

version: April 09, 2015 Angels Camp, California