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 for which I have been engaged.  I understand and agree that I am not to use the vehicle for any other reason whatsoever (human life threatening medical emergencies excepted).  I agree to operate this vehicle in a safe, prudent, and lawful manner at all times.  Seat belts shall be worn by all vehicle occupants when the vehicle is in motion.  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 in the State of Maine, have held such a license for at least one year, and that my privilege to drive is not currently under suspension.  I grant permission to the State to verify my Maine license information and driving record and offer the following license information:  	
Date of Birth	    /      /               	License Number & State				
(If not ME, applicant must provide a current copy of his/her driving record) 

	
One of the following MUST be checked:	
	(1) I do truthfully state that, in the past 5 years, my license was not suspended and I was not convicted or adjudicated of any alcohol or drug-related driving violations, or of any unsafe vehicle operations such as distracted driving, speeding, improper passing, failure to yield right-of-way, or stop sign violations.	
	(2) I do truthfully state that, in the past 5 years, my license was suspended or I was convicted or adjudicated of the following vehicle violations (please list; attach another page if necessary):	
	Type of violation:		Date:	    /     /	
	Type of violation:		Date:	    /     /	
	
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 IN ITS DISCRETION 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.  

If box #2 is checked, Risk Management Division reserves the right of final approval and the 
vehicle may NOT be operated by this driver until approved by Risk Management Division.
	
			    /     /		
	Driver Signature		Date Signed		
			    /     /		
	Signature and Title of Authorizing Entity Official		Date Signed		
					Official’s Phone #			
	Printed Name of Authorizing Entity Official		Printed Department/Entity Name		Official’s Fax #			
PROCESSING DIRECTIONS:  When ALL of the above information is completed, immediately send or fax this form to Risk Management Division, 85 State House Station, Augusta, ME 04333-0085; Fax 287-4008.  RMD will contact you promptly.  If you have any questions, call 1-800-525-1252 or 287-3351.	

For Risk Management Division Use Only
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. 11/17