UNITED STATES DEPARTMENT OF THE INTERIOR 

BUREAU OF LAND MANAGEMENT 

Fire and Aviation 

MOTOR VEHICLE OPERATOR’S AUTHORIZATION 

TO BE COMPLETED BY EMPLOYEE 

Employee Name (as on license) Employee Mailing Address (as on license) 

Office ID (e.g., FA-200) Employee Date of Birth (mm/dd/yyyy) 

Employment Status (circle one): 

 P – Permanent; TERM – Term; TEMP – Temporary; PPT – Permanent Part-Time; CS – Career Seasonal; V - Volunteer

CURRENT DRIVER’S LICENSE INFORMATION 

State of Issue License Number Date Issued Date Expires 

Do You Have a Commercial Driver’s License (CDL)? 

(Circle One) YES NO CDL No.

Date CDL Physical Expires

Is your current license valid in the state where you are domiciled? 

(Circle one) YES NO 

Previous license in state/s (within past three years) 

State/s: 

Date of Last Defensive Driving Course: Date of last 4WD Driving/ATV Course: 

PRIVACY ACT STATEMENT 

Section 6311 of Title 5 to the U.S. Code authorizes collection of this information. The sole use of this information is by your employing 

office for the purpose of verifying that you possess a valid state driver’s license. Executive Order 9397 authorizes collection of this 

information. Furnishing the information on this form is voluntary, but failure to do so may result in your not being authorized to operate a 

vehicle in the performance of your job. If your agency uses the information furnished on this form for purposes other than these indicated 

above, it may provide you with an additional statement reflecting those purposes. 

 APPLICANT – PLEASE READ! 

Severe penalties are provided for unofficial use of Government-owned or leased vehicles by 31 U.S.C. 1349, Adverse Personnel Actions, as 

follows: 

 “...Any officer or employee of the Government who willfully uses or authorizes the use of any Government-owned motor 

vehicle or aircraft, for other than official purposes or otherwise violates the provisions of this paragraph shall be suspended 

from duty by the head of the department concerned, without compensation, for not less than one month, and shall be 

suspended for a longer period or summarily removed from office if circumstances warrant.” 

The term “official purposes” does not include the transportation of officers and employees between their domiciles and places of 

employment except in cases of officers and employees engaged in field work, the character of whose duties makes such transportation 

necessary and such transportation has been approved by officials authorized to do so. 

MOTOR VEHICLE OPERATOR’S AFFIDAVIT 

I hereby certify that I will comply with the rules and regulations governing the use of Government-owned or leased motor vehicles, and that 

I have read and understand the penalties for unofficial use. 

Signature of Applicant Date 

TO BE COMPLETED BY THE SUPERVISOR 

The above-named applicant is authorized to operate a Government-owned or Government-leased vehicle while in the performance of his/her 

official duties, provided he/she has a valid State driver’s license in his/her possession at all times while driving: 

Identify Types of Vehicle/s Authorized to Operate (i.e., Passenger, Pickup, 4 WD, Truck/Trailer, Tractor/Trailer, ATV, Snowmobile) 

Restrictions 

Signature of Supervisor Title Date 

Area or Division 

 NIFC 1112-3 (03-2010)