Colorado School of Mines
Fleet Services

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.

New □
Renewal □

Print Neatly or Type.

Last, First, MI

Mines Email Address

Dept. Vehicle Coordinator
Telephone Number

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 #
Campus Phone

Print Name (Must be Department Supervisor/DVC)

Signature (Must be Department Head VC)

Email or Campus Mail to:
Mines Facilities Management - Fleet Services

Attachment A
Fleet Program
Updated 8/2/17

Please allow 10-15 working days.

Document Outline