Driver Eligibility Acknowledgement Form

It is Company policy to ensure that employees driving vehicles for business purposes are licensed and insurable. Only
employees who maintain a valid, unrestricted driver's license will be permitted to drive a vehicle for Company business.

Please complete the below form indicating the current status of your state/province/country driver's license and your
acknowledgement of your eligibility or ineligibility to operate a vehicle for Company business.

NOTE: The following form is required for all employees, even those whose regular job duties do not include the operation of
a vehicle for Company business.

Employee ID 0157223
Name NABILAH HUSNA BINTI HASBULLAH Location JOHOR BHARU

OPTION #1: I do not have a valid, unrestricted driver's license.

By selecting this option I acknowledge that I am not permitted, under any circumstances, to operate a
vehicle for business purposes.

OPTION #2: I have a valid driver's license with the following restriction(s).
By selecting this option I acknowledge that I am legally eligible to operate a motor vehicle but only when the
following restrictions are met.
Restriction(s):

OPTION #3: I have a valid, unrestricted driver's license.

By selecting this option I acknowledge that I am legally eligible to operate a motor vehicle with no
restrictions.

If you selected Option #2 or Option #3, please enter your driver's license information below AND submit a photocopy of the
front and back of your driver's license card to the Insurance Department via email (insurancemvr@fastenal.com) or fax (507-
494-9802).
Driver's License Number 0116101 h7suxyHy

State / Province Issued JOHOR BHARU

Country Issued MALAYSIA

By my signature I acknowledge that the above information is complete and accurate to the best of my knowledge.
Signature

Date 4 SEPTEMBER 2023

Please submit completed form via fax (507-494-9802) or email (insurancemvr@fastenal.com).