B&A Form (Complete)

B&A
B&A
BAKER & ASSOCIATES INSURANCE AGENCY
Motor Vehicle Record Release and Authorization Form

I hereby authorize the employer below to release and disclose my personal information to their insurance agency, Baker & Associates Insurance Agency. I hereby agree to release the below named employer, and Baker & Associates Insurance Agency, including without limitation its predecessors, successors, parent companies, subsidiaries, employees, agents, representatives, and assigns, from any claims for damages I may have based upon its release and disclosure of such information.
Employer Name
Employer Address
Employer City, State Zip
Name and Address of Insurance Agency
Full Name
Driver's License Number
CDL Drivers / # Years' Experience
Please answer how many years of experience you have with your CDLs and driving
Date of Birth

MonthDayYear
Date
Gender
Please write your gender?
State License Issued in
Social Security Number
This Authorization shall continue in effect until revoked by the undersigned in a subsequent writing delivered to the employer. I have read the foregoing and agree to be bound by the terms of this
Signature

Clear
Date

MonthDayYear
Date
Please Note: Due to Federal privacy regulations Baker & Associates Insurance Agency is not able to provide

you with a copy of your report or discuss its contents with you in any way. You should obtain your complete official report from the Ohio Bureau of Motor Vehicles. You may want to view your two (2) year Ohio free

access unofficial report at: https://services.dps.ohio.gov/BMVOnlineServices/DL/Abstract

ONCE COMPLETED, KEEP A COPY ON FILE IN THE EMPLOYEE'S PERSONNEL FILE.

AUTHORIZATION REQUIRED FOR AUDIT PURPOSES.

614.771.1212 800.543.0848 Fax: 614.771.1233 Suite A P.O. Box 220

B&A

B&A

BAKER & ASSOCIATES INSURANCE AGENCY