Original version: http://www3.babson.edu/offices/public_safety/forms_regulations/drivershistquestionnaire.cfm

DRIVING HISTORY QUESTIONNAIRE

This form must be completed and submitted prior to attending the Public Safety Van Certification Class. Certification is required for members of the Babson Community who need access to the Public Safety Vans for school related use. Individuals must present a valid Driver's License at the time of the class.

Fall 2007 classes take place on Thursdays, from 4-7 pm and on Sundays, from 12-3 pm. The class schedule is subject to change.

If you would like to attend a class, please enroll at least 24 hours in advance of the class.

IMPORTANT: All Van Certification applicants MUST read and agree to comply with the Vehicle Use Agreement & Regulations. Please read the agreement prior to submitting the following form.

Today's Date:

Select One:

First Name:

Last Name:

Grad Year:

Campus MailBox #:

Date of Birth:

mm/dd/yy

Group/Dept. Driving For:

Phone #:

Email:

Driver's License #:

State:

Expiration Date:

mm/dd/yy

License Revoked/Suspended?:

Yes

Has your license been revoked/suspended in MA or in any other state?

Driven at least 2000 miles in the past two years?:

Yes

Any traffic violations/accidents?:

Yes

Have you been charged with any traffic violations or involved in any accidents while driving your own or any motor vehicle during the last 18 months?

If yes, please describe each incident:

Include date, city/state and a description of the violation/accident.

Would you drive for other campus groups?:

Yes

Occasionally, faculty/staff/alumni/graduate organizations contact Public Safety when they need a van certified driver for a special event.

Would you expect compensation?:

Yes

You are required to notify Public Safety if your license is revoked or suspended for any reason. Babson College Department of Public Safety has the legal right to check your driving record with any government motor vehicle authority.

Vehicle Use Agreement & Regulations:

Agree to comply

All drivers are required to read, understand and comply with the Vehicle Use Agreement and Regulations. Any failure to comply with the mandatory regulations may result in disciplinary action and/or removal of driving privileges.

Signature:

By typing your name, you are certifying that all information provided above is correct and truthful. Any falsification of information or failure to comply with the mandatory van safety/operating regulations may result in disciplinary action and/or removal of driving privileges.

Babson College
Babson Park, MA 02457
Phone: 781-235-1200