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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:

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

That the undersigned authorizes his or her driving record to be periodically obtained and reviewed for the purpose of initial and continued employment.

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.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

May 20, 2021 8:17 pm CDT

Authorization to Obtain Motor Vehicle Record Uploaded by Randy Bacik - randy@glasscasa.com IP 192.168.0.1

October 12, 2022 10:34 am CDT

Cathy Shields - cathy@glasscasa.com added by Randy Bacik - randy@glasscasa.com as a CC'd Recipient Ip: 192.168.0.1