Non-NAU Credentialed Driver Authorization Request

This form is intended for students/volunteers requesting to become an Authorized Driver at NAU and who do not have NAU employee credentials.
If you have or will be receiving NAU employee login/CAS credentials, do not use this form.

Full name * Required
First Middle Last
Issuing state * Required
Date of Birth * Required
MM slash DD slash YYYY
Drivers License Number * Required
Email address * Required
ID Number * Required

EMPLID, or other University ID
I am a: * Required
- Student
- Volunteer or Affiliate
- Employee who was instructed to use the non-credential system
* Required
- I understand that the Driver Protection Privacy Act of 1994, amended 09/97, prohibits the release of my MVR data for other than bona fide driver selection and supervision activities. In accordance with this act and Arizona Code R2-10-207.12, I hereby authorize Northern Arizona University, its agents, and designees to use this information for access and periodic reviews of my MVR for the limited purposes noted above. By submitting this information, I represent it is true, correct, and complete to the best of my knowledge.
Phone
This field is for validation purposes and should be left unchanged.