Authorization For MVR Report
*Submitter's E-mail Address:
 

BY FILLING OUT THIS FORM, I HEREBY STATE THAT:
  1. I am an employee or prospective employee of the above named business.
  2. I authorize this employer or prospective employer or it agent(s) to obtain my Motor Vehicle Report ("MVR") to be used for the following purposes:
    1. To verify the information relating to my license and qualifications to determine whether I should be an employee to operate a commercial vehicle.
    2. By the Company's insurance carrier for underwriting purposes.
  3. I understand that "Commercial Vehicle" means any vehicle for which the principal use is the transporation of commodities, merchandise, produce, animals, or passengers for hire.
  4. I have been advised, and hereby acknowledge and agree, that the information contained on my MVR may be sent between the parties via facsimile or email, both of which are non-secure modes of transmission.
  5. I further understand that no information contained in the MVR shall be divulged, sold, assigned or otherwise transferred to any third party or person.
 

DRIVERS LICENSE INFORMATION
1. Do you have a valid Drivers License? Yes No
 
License Number Issuing State Date of Birth
(dd/mm/yyyy)
2. Have you had any DUIs in the last 7 years? Yes No

If yes, how many?


3. Have you had any moving violations in the past 7 years? Yes No

If yes, how many?
 
* Name
   Address
   Approved by
(Authorized Company Representative)
 
 I certify that all employees noted above have given consent to having their motor vehicle records checked.