Student Van Familiarization Application Policy Please familiarize yourself with the Vehicle Use Guidelines and the University/State Vehicle Use Policy (E.1.2) available on BoardDocs. NameThis field is for validation purposes and should be left unchanged.University Department InformationPlease enter the sponsoring department’s information.Supervisor/Sponsor Name * Required First Last University Department * RequiredDepartment PhoneApplicant Personal DataPlease enter student’s information.Name * Required First Last This field is hidden when viewing the formDate of Birth * Required MM slash DD slash YYYY Banner ID * RequiredPhone Number * RequiredUMW Email * Required Permanent Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please Read and Accept to continue * RequiredI 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 DeclinedYou 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.This field is hidden when viewing the formDriver's License Number * RequiredState * RequiredDate Issued * Required MM slash DD slash YYYY Expiration Date * Required MM slash DD slash YYYY Any Restrictions? * RequiredYesNoThis field is hidden when viewing the formRestriction Description * RequiredTotal Road Experience as a Licensed Driver * RequiredYearsMonthsType of Vehicle Currently DrivenDriver HistoryPlease check information to ensure accuracy. Incorrect information may delay scheduling.DUI / DUID (past 2 years)Please enter ‘N/A’ if this does not apply.ReasonDateStateFine Tickets (past 2 years)Please enter ‘N/A’ if this does not apply.ReasonDateStateFine Accidents (past 2 years)Please enter ‘N/A’ if this does not apply.ReasonDateStateFine Preferred Class DateClasses are held on Wednesdays from 3pm – 5pm. Scheduling is based on availability. If the class on the preferred date is full, you will be placed in the next available class. MM slash DD slash YYYY Certification and AgreementBy 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 * RequiredBy entering your name below, you are agreeing to the certification stated above. First Last Δ