Online MVR Form

DISCLOSURE AND AUTHORIZATION FOR RELEASE OF

MOTOR VEHICLE RECORD (MVR) INFORMATION

I authorize Vassar College and its designated agents and representatives, including but not limited to the company's insurance agent(s) and/or legal representative to obtain and review my motor vehicle record (MVR) information. I voluntarily supply the information necessary to obtain driver license information from any state where I have been licensed to drive a motor vehicle and release all parties involved from liability for doing so. I have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the report and a copy of my Consumer's Rights under the Fair Credit Reporting Act.

This authorization shall be valid in original, fax, email or copy form and shall serve as an ongoing authorization to procure MVR information on an ongoing basis during my employment, membership, contract period or enrollment.

Fill out the information below so your MVR information can be obtained.

Last Name

First

Middle

Address

City, State, Zip Code

DOB (mm/dd/yyyy)

Driver License No

License Class (usually a letter designation)

Issuing State

Have you ever held a driver license in any other state other than the above, mentioned issuing state?

If yes, list state(s)

In the past 5 years have you ever been convicted of a traffic offense (not including parking tickets) in any other state?

If yes, list state(s)

MUST CHECK ONE

StudentVolunteerProspective EmployeeEmployee

Reason for use

Department/Student Organization

Digital Signature:

Checking this box, constitutes an effective original signature and may be used with the same effect as a manually signed original.

Date(mm/dd/yyyy)

Date