Federal Drivers Policy Protection Act

Authorization to Obtain a Motor Vehicle Report

"*" indicates required fields

Type of Hire*

New Employee

Returning Employee

Date Last Employed*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Drivers License Number*

Drivers License State*

Date of Birth*

Email Address*

Check to Authorize*

For the sole purpose of the determinations and evaluation of my motor vehicle operating record and pursuant to the State and Federal regulations of compliance, I authorize Harding Brooks Associates LLC to obtain my Motor Vehicle Record for insurance underwriting/eligibility purposes. I understand that this record may contain person information in addition to any/all driver violations and/or accidents. which may be on records through the Department(s) of Motor Vehicles.

Check to Authorize*

I also authorize release of this insurance underwriting/eligibility information to my employer (or proposed employer).

Check to Authorize*

Personal information means information that identifies an individual including an individual's photograph, driver identification number, name, address and telephone number.

Signature Date*

Signature*

Phone

This field is for validation purposes and should be left unchanged.