NOTARIZED STATEMENT OF DRIVING RECORD *
This is to inform you that I presently hold a valid driver's license from the state/country of ______________ and that the
following is a true statement of my driving record for the past three years. My driver’s license expires on ___________. I
have had a valid driver’s license for two or more years? _______ yes _______no.
1. I have been ticketed for the following moving violations (if none, please enter "None"):
Date____________________
Offense________________________________
2. I have been involved in the following accidents (if none, please enter "None"); if you have been involved in any
accidents within the past three years, please give a brief description of the accident(s):
__________
(Date)
_________________________________
(Signature)
_________________________________
(Print Name)
Subscribed and sworn to before me this _______day
of ________________________, 20______________
My commission expires _______________________
___________________________________________
(Notary Signature)
(SEAL)
* All UW System employees holding an out-of-state/country driver's license must complete this form in order to receive
driving privileges on behalf of the University of Wisconsin System.