Release for Driving Record (PDF Form)

Bockelman's Landscaping, Inc.
2869 Youngstown-Kingsville Rd., Cortland, OH, 44410
phone: 330-638-5296 | fax: 330-638-2520
email: apply@bockelmans.com

REQUEST FOR CHECK OF DRIVING RECORD

I hereby authorize the release of official driving record information to Bockelman’s Landscaping, Inc. for the purpose of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.


Applicant Signature		Date

Name of Applicant

First NameMILast Name

Date of Birth*

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security

##-###-####

License Number

Issuing State

e.g. OH, PA

I also hereby certify that this report request and the above applicant’s release notice meet the definition of “permissible uses” of State Motor Vehicle records under the provisions of the Driver’s Privacy Protection Act of 1994 (Public Law 103-322 Title XXX Sections 300002(a)).


Requestor Signature		Date