Authorization to Drive a Motor Vehicle

Vehicle Owner (Owner)
Name: ______________________________
Address: ____________________________
Address: _____________________________
Home phone: ____________________	Work phone: ____________________
Cell phone or pager: ____________________	Email: ____________________
Vehicle
Make, model, and year of vehicle: _______________
Vehicle license plate number: _______________
State of registration: _______________  Vehicle registration number: _______________
Insurance company: _______________
Insurance policy number: _______________
Person Authorized to Drive (Borrower)
Name: _______________
Address: ____________________________
Address: _____________________________
Home phone: ____________________	Work phone: ____________________
Cell phone or pager: ____________________	Email: ____________________
Driver's license number: _________________
Motor vehicle insurance company (if any): _______________
Insurance policy number (if any): _______________

Authorization and Consent of Vehicle Owner
I am the lawful owner of the vehicle indicated above. I give my authorization and consent for Borrower to use this vehicle as follows:
Dates of use: _______________
Area in which vehicle may be used: _______________
Any restrictions or conditions on use: ________________________________________

I declare under penalty of perjury under the laws of the state of ______________________ that the foregoing is true and correct.

_____________________________________________________
Owner’s signature
Date: _______________