ࡱ> <>;U bjbjnn 0,aa $$$$Lp$_!  $E#%z!LK@LL!!***L" *L **n: /!0_!u&Du&u& Z@*%4Y!!>_!LLLLu&B :  February 2019 Request for Check of Driving Record Applicant: Must complete Top and Bottom sections I hereby authorize you to release the following information to ݮƵ (named insured) for purpose of authorization to drive college vehicles as required ݮƵ and Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. ______________________________________________________ ____________________________________ Print Applicants Name Date Contact Phone/Cell Number____________________________ E-mail Address_________________________________ Strick out and initial: I do / do not have experience driving vehicles with chassis one ton or larger 12 or 15 passenger vans (circle one) with 6 or more seats. In accordance with the provisions of Section 604 and Section 607 of the Fair Credit Reporting Act, Public Law No. 91-508, I hereby certify that the information requested below will be used for a permissible purpose as defined in the Act, and that the information received will be used for no other purpose. I further certify that if the applicant named below is denied authorization to drive a ݮƵ vehicle based upon the information received, I will identify the source of the report in accordance with Section 615(a) of the Fair Credit Reporting Act. _______________________________________________________________________________________________ Applicants Signature for MVR check approval Date _______________________________________________________________________________________________ Authorized MC Dept. Insureds Signature Date  RTURN TO: ݮƵ Attn: Cindy Nutter  HYPERLINK "mailto:can003@marietta.edu" can003@marietta.edu or Fax: 740-376-4409 The below named person has requested authorization to drive a ݮƵ vehicle. In accordance with college policy and Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with either a favorable or unfavorable recommendation to drive based on the applicants driving record for the past three years. Name of Applicant_______________________________ Social Security #______________________________ (print) (required) Address on drivers License ________________________________________________________________ Street City State Zip Date of Birth _______________________________ License Number___________________________ State of Issue ________________________________ Exp. 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