Office of Risk Management 2020 Ridge Avenue, Suite #240 Office: 847/467-7795 | Fax: 847/467-7475

www.northwestern.edu/risk

APPLICATION TO USE NU VEHICLES. DATE

LAST NAME FIRST NAME MIDDLE INITIAL.

EMAIL ADDRESS CONTACT NUMBER

NAME OF NU GROUP DRIVING FOR COURSE APPLYING FOR ☐ DEFENSIVE DRIVING ☐ GOLF CART COURSE

IS THIS YOUR FIRST TIME TAKING THE COURSE? Y / N WOULD YOU LIKE AN EMAIL COPY? Y / N

INFORMATION AS IT APPEARS ON YOUR CURRENT DRIVER’S LICENSE MUST BE LICENSED DRIVER FOR 2 YEARS AND LICENSE MUST BE RECOGNIZED BY THE STATE OF ILLINOIS. ISSUING STATE DRIVER’S LICENSE NO. EXPIRATION DATE

STREET ADDRESS CITY ZIP CODE

DATE OF BIRTH LICENSED FOR AT LEAST 2 YEARS? Y / N

MORE THAN TWO MOVING VIOLATIONS? Y / N

I certify that in the past year, I have a driving record free of any two moving violations or one moving violation and one accident, or two accidents, or any single alcohol related stop.

I also certify that I have held a valid driver’s license for the past two years. I also understand that in the event I receive two moving violations, or one moving violation and one

accident, or two accidents in one year, or any single alcohol related stop, my Northwestern University driving privileges may be revoked.

I also authorize Northwestern University and Rubicon Insurance Company to obtain a copy of my driving record.

SIGNATURE DATE

FOR OFFICE USE ONLYCOURSE COMPLETION DATABASE

DDC MVR ☐ENTERED☐SCANNED☐CERTIFICATE CREATED

INITIAL_________________ ☐PASS ☐FAIL SUBMITTED APPROVED

GOLF CART COURSE CERTIFICATE

☐PASS ☐FAIL ☐PRINTED ☐EMAILED