VEHICLE USE AGREEMENT 
I (print name)		being age 18 or older, understand and agree that my use of the	

If driving history includes out-of-state license, applicant must attach out-of-state driver record.

State of Maine vehicle assigned to me from _____/___/_______ to ______/___/_______ (maximum 1 year) shall be exclusively to fulfill the State of Maine business.  I understand and agree that I am not to use the vehicle for any other reason (life threatening medical emergencies excepted).  I agree to operate this vehicle in a safe, prudent, and lawful manner at all times.  I will not permit any other person to operate the vehicle.  I will not drive this vehicle out of the State of Maine.  I do truthfully state that I have an active, non-conditional driver’s license recognized as valid and my privilege to drive is not under suspension.  I grant permission to the State to verify my driving record:  	
Date of Birth	    /      /               	License Number & State				

	
One of the following MUST be checked:	
	(1) I truthfully state that, in the past 5 years:  my license was not suspended, I was not convicted of alcohol or
 drug-related violations or unsafe vehicle operation. I was not the driver of an at fault motor vehicle accident. 	
	(2) I truthfully state that, in the past 5 years, my license was suspended, was convicted of the following vehicle violations, or involved in a motor vehicle accident (please list; attach another page if necessary):	
	Type of violation/accident:		Date:	     	
	Type of violation/accident:		Date:	  	
	
If box #2 is checked, the vehicle may NOT be operated by this driver until approved by Risk Management.

IMPORTANT NOTICE TO DRIVER:  do not sign below unless you have read and understand this document.  By signing, you agree that if you make any false statements on this document or use a state-owned vehicle other than as permitted by this agreement, risk management division may decide not to insure your operation or use of a state-owned vehicle and may decline to defend and indemnify you in the event a claim is brought against you.	
			 		
	Driver Signature		Date Signed		
			 		
	Signature of Supervisor/Manager		Date Signed		
					Phone#			
	Printed Name of Supervisor/Manager		Department Name		email 			

Completed VUA’s can be faxed to 287-4008. Incomplete forms will be rejected. If you have any questions, call 1-800-525-1252 or 287-3351. 

o Approved o Not Approved  o Approved with this restriction: ___________________________________________________ 
Entity notified this date   By: o Fax o Phone o Email o Other _________________________________________________
Risk Management Division Signature: ________________________________________ Date:        /       /             Rev. 8/23