AUTHORIZATION TO OPERATE AND DRIVE

• VEHICLE OWNER

NAME: ______________________________________________________
ADDRESS: ______________________________________________________
PHONE: ______________________________________________________
EMAIL: ______________________________________________________

• VEHICLE AND IDENTIFYING INFORMATION

MAKE, MODEL AND YEAR OF MODEL: __________________________________

VEHICLE LICENSE PLATE: __________________________________
STATE REGISTRATION: __________________________________
VIN: __________________________________
INSURANCE COMPANY: __________________________________
INSURANCE POLICY NUMBER: __________________________________

• PERSON AUTHORIZE TO OPERATE, ASSIGN AND DRIVE

NAME: ______________________________________________________
ADDRESS: ______________________________________________________
PHONE: ______________________________________________________
EMAIL: ______________________________________________________
LICENSE: ______________________________________________________

• PERSON AUTHORIZE TO DRIVE

NAME: ______________________________________________________
ADDRESS: ______________________________________________________
PHONE: ______________________________________________________
EMAIL: ______________________________________________________
LICENSE: ______________________________________________________

I am the lawful owner of the vehicle indicated above. I give my authorization and consent for
_______________________________, to use this vehicle as follows;

Date of use: _____________ until my written termination.

Area of use: Nationwide

I declare under penalty of perjury under the law that the foregoing is true and correct.

____________________________
LESLIE ANNE JOY D. ESCOTO

DATE: _____________________