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

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:

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

(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:

1.	Please confirm you are not an employee. 	
2.	What will driving operations entail? 	
3.	What vehicle(s) will be driven? The vehicle(s) need to be insured by either CFM or Risk Management.
•	If CFM vehicle(s), please confirm. (CFM vehicle info not needed). 	
•	If agency vehicle(s), the year, make & model is needed. 	
4.	Will there be any out-of-state driving? 	

         ____________________________________________________________     _______________________________________
Driver Signature	Date Signed

Signature of Supervisor/Manager	Date Signed

Printed Name of Supervisor/Manager	Department Name

Phone #		
Email		

Do not sign 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.

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. 03/25