Student Van Familiarization Application

Student Van Familiarization Program

Student Driver Application Questionnaire

University Department Information
Please enter the sponsoring department's information.
Supervisor/Sponsor Name * Required
First Last
University Department * Required
Department Phone
Applicant Personal Data
Please enter student's information.
Name * Required
First Last
Date of Birth - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Banner ID * Required
Phone Number
Email * Required
Permanent Address * Required
Street Address Address Line 2 City State ZIP Code
Please Read and Accept to continue * Required
I give my permission for the University of Mary Washington to access my driver's license record and continue to monitor it through Drive Alert, a program administered through the Virginia Department of Motor Vehicles.
- Accept
- Decline
Driver Record Check Declined
You must allow UMW to check your driving record through the VA DMV's Drive Alert in order to take the Van Familiarization class. Please select 'Accept' or to discontinue, close the application.
License Information (VA LICENSE ONLY)
Please check information to ensure accuracy. Incorrect information may delay scheduling.
Driver's License Number * Required
State * Required
Date Issued - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Expiration Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Any Restrictions? * Required
Restriction Description * Required
Total Road Experience * Required
Years Months
Type of Vehicle Currently Driven
Driver History
Please check information to ensure accuracy. Incorrect information may delay scheduling.
DUI / DUID (past 2 years)
Please enter 'N/A' if this does not apply.
Reason Date State Fine
Tickets (past 2 years)
Please enter 'N/A' if this does not apply.
Reason Date State Fine
Accidents (past 2 years)
Please enter 'N/A' if this does not apply.
Reason Date State Fine
Preferred Class Date - must be mm/dd/yyyy format
Classes are held on Wednesdays from 4pm - 6pm. Scheduling is based on availability. If the class on the preferred date is full, you will be placed in the next available class.
Date Format: MM slash DD slash YYYY
Certification and Agreement
By signing this application to operate a Commonwealth of Virginia vehicle, I certify that: * Required
- The information contained above is accurate
- I have read, understand and agree to the UMW Policy concerning the operation of a Commonwealth of Virginia (UMW) vehicle
- I agree to a DMV check and validation (Applies to all individuals operating Commonwealth of Virginia vehicles)
Electronic Signature * Required
By entering your name below, you are agreeing to the certification stated above.
First Last
Name
This field is for validation purposes and should be left unchanged.

Reason	Date	State	Fine

Reason	Date	State	Fine

Reason	Date	State	Fine

Student Van Familiarization Application

Student Van Familiarization Program

University Department Information

Applicant Personal Data

Driver Record Check Declined

License Information (VA LICENSE ONLY)

Driver History

Certification and Agreement

Parking Map