Driving Authorization Form
Driver Details
Driver’s name: Md. Akash Ali
Function & Location: Sales & Jessore
Line managers’ name: Manoshi Mojumder
Date of Birth: 12 July, 1996
Total years of driving experience: 5
Driving license details: DK0818543CL0005 (Light & Motorcycle)
Type of vehicle (tick as appropriate): 4W / 2W
Driver group as defined in the Driving Safety
Specifications (tick as appropriate, see table 1 for (Occasional/Medium Risk/At Risk)
reference):
Items Yes No Remarks
Driver has a current license for the class of vehicle to
be used √
Driver has not had a history of serious traffic violations √
Driver is trained in basic defensive driving techniques √
Driver has completed defensive driving training (DDT)
& practical assessment and qualified* √
Driver has no previous motor vehicle incidents records
Required medical checks (such as eyesight testing,
drug test and medical fitness) has been conducted and
found fit to operate a vehicle (please attach medical
report and visual assessment)
*All drivers and riders must complete basic defensive driving induction immediately before
driving Syngenta vehicle, attend face to face DDT and assessment within 3 months of joining ,
refreshers training in every 2 years.
Authorizer Name & Sign
Designation:
Date:
Driver Visual Fitness Check
Name: Date:
Designation:
Type of Vehicle (Please tick): 4-Wheeler 2-Wheeler
Checked by (Doctor Name and Signature): ………………….
1. Are you able to identify any objects, signs, vehicles at
Please answer below questionnaire daytime or night and can correctly judge distance / depth
to assess driving fitness check. Tick while driving?
on the box to select Yes or No, Yes No
If no then please describe
here………………………………………………………………………………………………………………………………………
2. Are you able to physically fully control and operate the vehicle safely (i.e.: able to move
neck, back, arms, hands and legs)?
Yes No
If no then please describe
here………………………………………………………………………………………………………………………………………
3. Able to hear warning sounds and spoken instructions (with disability aid if necessary)?
Yes No
If no then please describe
here………………………………………………………………………………………………………………………………………
4. Do you have any of cardiovascular risk (blood pressure, pulse, heart conditions etc.) or
neurological conditions e.g.: multiple sclerosis, Parkinson’s disease, stroke, epilepsy
etc.?
Yes No
If yes then please describe
here……………………………………………………………………………………………………………………………………
5. Do you have of any possible psychiatric problems e.g. psychosis, dementia, depression,
anxiety neurosis etc.?
Yes No
If yes then please describe
here………………………………………………………………………………………………………………………………………
Table 1: Syngenta Driver & Rider Classification
