Occidental College Authorized Driver Application

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OCCIDENTAL COLLEGE
A
D
A
UTHORIZED
RIVER
PPLICATION
Please submit a photocopy of your driver’s license with application. Non-student employees may initially provide an
out of state license and provide a valid California driver’s license within 30 days of applying. Applicants must have at
least 2 years licensed driving experience. Please print or type:
________/_______/_______
Last Name
First Name
M.I.
Date of Birth
________
______/______/______
License No.
State
Exp. Date
E-mail address
2 or more years continuous licensed driving experience: Yes
No
NOTE: If your driving experience
in last 2 years is in multiple states, please list all states you were licensed in: _______________________
fr.
so.
jr.
sr.
Employee/Applicant
Student
Department & Supervisor
Local Address
Oxy ID #
Box
City, State, Zip Code
Local Phone Number and/or Oxy extension
In consideration of Occidental College’s (“College”) review of my application for Authorized Driver status, I hereby
voluntarily consent to and authorize the College, or its authorized agents bearing this release or copy thereof, to obtain a
consumer report which may include driver history or motor vehicle records for the purpose of determining my eligibility to
be an Authorized Driver in connection with my potential employment, employment responsibilities, or other College
approved activities. I authorize the College to obtain my driver history or motor vehicle records through American
Driving Records, Inc. (“ADR”), a consumer reporting agency, or through the California Department of Motor Vehicles
(“DMV”). I hereby release the College, its authorized agents, and all persons and organizations providing this
information from all claims and liabilities of any nature whatsoever in connection with this research. I hereby further
authorize that a photocopy of this authorization may be considered as valid as the original. I agree that this authorization
shall remain on file and shall serve as ongoing authorization for Occidental College to procure driver or motor vehicle
records at any time during my employment or enrollment period.
I hereby acknowledge receipt of the Occidental College Authorized Driver Procedures and Vehicle Rental Procedures. I
agree that if I am granted Authorized Driver status, I will comply with all requirements of the Authorized Driver and
Vehicle Rental Procedures. I further acknowledge my understanding that if I am granted Authorized Driver status and
drive my own vehicle on College approved business or activities, my liability insurance is primary and I am solely
responsible for any physical damage to my personal vehicle. I further acknowledge that if I am transporting passengers
on College approved activities in my personal vehicle, I must obtain a signed Occidental College Passenger Waiver from
all passengers.
I hereby acknowledge my understanding that if I am denied Authorized Driver status or my Authorized Driver status is
revoked, I am prohibited from driving on College business or for College approved activities. I understand that if the
College’s review of my driver history or motor vehicle records results in denial or revocation of Authorized Driver
status, such denial may result in adverse action(s) up to and including denial of or loss of employment. I understand that
I have specific prescribed rights as a consumer under the federal Fair Credit Reporting Act (“FCRA”) and may have
additional rights under relevant California state law. I understand that under the College’s Authorized Driver
Procedures, I may have the right to appeal denial or revocation of Authorized Driver status. I hereby certify that I have
been presented with summaries of my rights as a consumer under FCRA and under California Investigative Consumer
Reporting Agencies Act.
_____________________________ ________________________________
_______________________
Signature
Printed Name
Date
DDA FY08-098/19/08/10/1/11

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