Personal Vehicle Registration

Personal Vehicle Registration for Student Organization Approved Travel
Name of student using a personal vehicle: **
Student Organization*
Driver of Vehicle
Birth Date*
MM slash DD slash YYYY
Student ID number*
Driver’s License
State*
Number*
Expiration Date*
Vehicle
Year/Make/Model:*
License Number:*
Owner:*
Vehicle Insurance
Insurance Company:*
Policy Number:*
I hereby certify that I am at least 18 years of age, that I currently hold a valid driver’s license, that I have not been convicted of any major traffic violations within the past 36 months.

As long as I use my vehicle for approved travel for my CSA chartered student organization, I will keep the above insurance (or equivalent) in force, and that all of the above statements are true. I am aware that in the event of an accident, my vehicle insurance is primary.

In addition to completing this form, I will complete the following online Driver Safety Training and become an Authorized Student Driver Application as listed below prior to travel. To access the driver training course, students should navigate to the United Educator’s Learning Portal. Once an account is created, United Educators will email a temporary password needed for access.

Students may complete the courses in sections and resume where they left off. The United Educator’s site will provide the Student Activities Office with a report of who completed the course. Students may also print a certificate for their records.

Authorized Student Driver Application
Name
First Last
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Personal Vehicle Registration

Personal Vehicle Registration for Student Organization Approved Travel

Driver of Vehicle

Driver’s License

Vehicle

Vehicle Insurance