NOAO/NSO Application for a Motor Vehicle Operator's Identification Card


Visitors and staff of NOAO-Tucson, including Kitt Peak, must apply and be approved for a Government Services Administration (GSA) driver's license before being allowed to operate any NOAO and Kitt Peak vehicles within the United States. Please complete the form below and hit "Enter." Your application will be delivered to the CFO office in Tucson, and you will receive a confirming e-mail after your application has been processed.


Name: Email address:
Organization:

Please enter your mailing address below (include zip code).

Have you previously been issued an ID card or a GSA license from this office?
       No    Yes
Please select the appropriate item below that bests describes your current status.
       NOAO/NSO staff    KPNO visitor    NSO visitor    Docent


SECTION A. PERSONAL DATA AND DRIVING RECORD


Current Driver's License Information:


State/Country: Number: Expiration Date:
Restrictions listed on license:
Birth date:   Sex:
Color hair: Color eyes: Height: Weight:



Driving Experience Within the Last Twelve Months:


Current Vehicles Driven:
  Car   Van   PickUp
Est. Miles Driven: Est. Days Driven:

Have you had any traffic violations (except parking) within the past 3 years?
       yes  no
Have you had any accidents within the past 5 years?
       yes  no
Has your license been suspended or revoked in the past 5 years?
       yes  no
If your answer is "Yes" to one or more of the above questions, explain fully in this space below, indicating the date of the occurrence, as well as the nature of the occurrence, where it occurred and what action was taken (use the "Return" key to break long lines):


SECTION B. PHYSICAL FITNESS INQUIRY



Do you wear glasses (or contact lenses) while driving?
       No    Yes
Do you wear a hearing aid?
       No    Yes

Have you ever had or do have you now have any physical limitations or medical issues that could affect your operation of motor vehicles?    yes no

If your answer is "Yes" to the above question, in the space below, indicate the date of condition and current status (use the "Return" key to break long lines):


PRIVACY ACT NOTICE


Authority: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals completing the Physical Fitness Inquiry. U.S. Code, Title 5, section 301.
Purposes and Uses: This form is used to ascertain the physical fitness of employees and official visitors who need to drive Government-owned motor vehicles. It is also used in the renewal of authorizations of all employees and official visitors.
Effects of Nondisclosure: Nondisclosure of this information will result in the individual not being authorized to drive a Federal motor vehicle. The disclosure of this information is mandatory when the individual needs to drive a Government-owned vehicle.


I certify that my answers above are full and true, and I understand that a willfully false statement or dishonest answer to any question may be grounds for denial, suspension, or revocation of the identification card.


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NOAO is operated by the Association of Universities for Research in Astronomy (AURA), Inc. under cooperative agreement with the National Science Foundation

Updated: 25Jul2003