Authorization for Driver's License History Report

Authorization for Driver's License History Report
Beacuse of the risk of accidents, Mid Michigan College's risk management policies require a driver's license history report be obtained and evaluated before an employee is allowed to operate a College vehicle.

Given the sensitive nature of information included in a driver's license history reports, College employees who are authorized to access these reports sign confidentiality agreements and the reports are maintained in a secured file by Procurement Services.
Employee Name (as it appears on your driver's license)*

First NameMiddle NameLast Name
Employee MidMich Email*
example@example.com
Employee Address (as it appears on your driver's license)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License Number*
Enter the number from your driver's license, including spaces.
Date of Birth*

MonthDayYear
Employee Signature*

Clear
Date Signed*

MonthDayYear
Significant effort has been made to ensure this content meets accessibility guidelines. If you encounter a barrier you can report the barrier at midmich.edu/reportaccessibilitybarrier or contact Business Services at (989) 386-6604 or ardept@midmich.edu.

In its commitment to providing a safe environment, Mid Michigan College actively endeavors to broaden our diversity, promote equal opportunity, and prohibit any form of discrimination in its programs, activities, and conditions of admission or employment. Learn more about these efforts and policies by visiting midmich.edu/eeo, midmich.edu/titleix, midmich.edu/securityreport.
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