Form Vsp-1 - Authorization To Operate State Vehicles And Private Vehicles On State Business

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ARKANSAS STATE VEHICLE SAFETY PROGRAM
AUTHORIZATION TO OPERATE
STATE VEHICLES AND PRIVATE VEHICLES ON STATE BUSINESS
APPLICANT MUST PROVIDE A COPY OF THE FRONT AND BACK OF DRIVER’S LICENSE
Agency Code: 710
Agency: Department of Human Services, Division of Children and Family Services
APPLICANT MUST COMPLETE AND SIGN THE FOLLOWING BEFORE
AUTHORIZATION TO DRIVE ON STATE BUSINESS WILL BE GIVEN:
DRIVER CATEGORY: (Please check one box)
Employee
Job Applicant
Foster Parent
Stipend Student
Volunteer
Other DCFS Affiliate (Specify) ____________________________
Driver’s Name: ____________________________________________________
Date of Birth:
____________________________________________________
Drivers License Number: ___________________________________________
Read and initial each of the following statements:
__________
I understand that as permitted by Arkansas Code Ann. 27-50-906 (6) (A), the Office of Driver
Services will notify my employer each time a new violation is added to my driving record. I
also understand that my employer has access to my driving record through the SVS System
(State of Arkansas Website) through Network of Arkansas.
_________
I understand that because of my driving record I may not be permitted to drive on State
business.
_________
I will participate in all required Defensive Driving classes.
_________
I will report all accidents that occur on state business to my employer 1) within 24 hours of
occurrence or by the next working day if the accident occurs in a State Vehicle and 2) within
7 working days if the accident occurs in a private vehicle.
_________
I have read the Driving Safety Tips.
_________
I understand that I must maintain liability coverage, as required by state law, on my personal
vehicles that I drive on state business.
Driver’s Signature: ______________________________________________ Date: __________________
VSP-1 (R. 09/2010)

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