Amador Hall 255
916-278-6504
TODAY'S DATE:
NAME:
PHONE:
EMAIL:
DEPARTMENT:
DATE OF TRIP:
TIME OF DEPARTURE:
TIME OF RETURN:
DESTINATION:
PURPOSE OF TRIP:
INSTRUCTOR(S):
NAME OF DRIVER(S):
MARK ONE: FACULTY STUDENT STAFF
I certify that I have a current, valid California Driver's License; that I am familiar with the contents of the Defensive Driver's Manual, and the CSU Vehicle Manual. I further certify that I have not been issued more than three moving violations or have been responsible for more than three accidents (or any combination of more than three thereof) during the past twelve-month period. As a student driver, I have signed the Volunteer Employee Form required by the University.
