Driver Authorization Form - State Of Louisiana Page 2
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1
2ANNUAL SUPPLEMENTAL SIGNATURE PAGE
EMPLOYEE NAME:_______________________________
DRIVERS LICENSE NUMBER:______________________
DEPARTMENT/AGENCY:___________________________
AGENCY HEAD OR DESIGNEE STATEMENT
By executing this document, I have reviewed the following and have confirmed the information to be
current and in accordance with the ORM Loss Prevention requirements:
Official Driving Record
Drivers Training Course
Further, my signature allows the aforementioned employee to drive a state vehicle, rental vehicle or
personal vehicle on state business.
______________________________
_________________________
Agency Head
Date of Authorization
(or designated individual)
______________________________
_________________________
Agency Head
Date of Authorization
(or designated individual)
______________________________
_________________________
Agency Head
Date of Authorization
(or designated individual)
______________________________
_________________________
Agency Head
Date of Authorization
(or designated individual)
______________________________
_________________________
Agency Head
Date of Authorization
(or designated individual)
______________________________
_________________________
Agency Head
Date of Authorization
(or designated individual)
______________________________
_________________________
Agency Head
Date of Authorization
(or designated individual)
(DUPLICATE SUPPLEMENTAL SIGNATURE PAGE AS NEEDED)
07/01/2011
DA 2054
Supp.-1
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