Authorization to Obtain Motor Vehicle Record


Full Name:

Drivers License Number: DL Expiration Date: DL Issuing State:  

DL Front Image: Date of Birth:  

Authorization to Obtain Motor Vehicle Record

 THE UNDERSIGNED DOES HEREBY ACKNOWLEDGE AND CERTIFY AS FOLLOWS:

  1. Certifies that the undersigned is an employee or has applied to become an employee of the below-named employer in a position that involves the operation of a motor vehicle and the undersigned gives his or her consent to the release of their driving record (MVR) for review by:

   Glass Casa Inc.  

Name of Employer or Potential Employer

  1. That the undersigned authorizes his or her driving record to be periodically obtained and reviewed for the purpose of initial and continued employment.
  1. That all information presented in this form is true and correct. The undersigned makes this certification and affirmation under penalty of perjury and understands that knowingly making a false statement or representation on this form is a criminal violation.

 

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Signature Certificate
Document name: Authorization to Obtain Motor Vehicle Record
lock iconUnique Document ID: 7666b085554654316113bb8f1ad60e7c3e388bc1
Timestamp Audit
May 20, 2021 8:17 pm CDTAuthorization to Obtain Motor Vehicle Record Uploaded by Randy Bacik - randy@glasscasa.com IP 12.250.100.42