Colorado School of Mines
Operator Approval Request
I am aware that a driver license record (MVR) check will be obtained as part of Mines evaluation to drive a
fleet vehicle, my job application or employment. The records may be procured by Mines or its insurance
company representative(s), and may include personal information obtained from the appropriate agency.
My driving record will be used as an assessment of my qualification as an approved vehicle operator.
By signing this form, I have read and understand the Mines Fleet policy and hereby provide my
authorization for Mines or their insurance company representative(s) to procure such information and
reports, as well as additional reports on an annual basis as deemed appropriate, to evaluate my continued
approved driver status.
Please select one.
Print Neatly or Type.
Last, First, MI
Mines Email Address
Dept. Vehicle Coordinator
Will you operate a 15-passenger van?
(Please make sure that you have/or will take the proper 15 passenger van training before
driving a 15 passenger van).
Must be signed by Operator Applicant.
Authorization: (For your Department to fill out)
Index Code #
Print Name (Must be Department Supervisor/DVC)
Signature (Must be Department Head VC)
Email or Campus Mail to:
Mines Facilities Management - Fleet Services
Please allow 10-15 working days.
- Please select one.
- Print Neatly or Type.