MVR Affidavit Form

MAC Pizza Management MVR Affidavit Form

If you possess a valid US driver's license and comply with Domino's Pizza and MAC Pizza's requirements for operation a motor vehicle in the course of your employment, but MAC Pizza is unable to run a Motor Vehicle Report (MVR) at this time on a prior driver license held in another country, you must sign an affidavit stating your prior driving record passes the MVR Standard. The affidavit contains a complete statement regarding your driving record for the past three (3) years. This affidavit may be used in this circumstance until the history can beverified. If, when we receive additional information regarding your driving history it indicates a driving history which does not pass the MVR Standard, you will be subject to disciplinary action up to and including immediate termination.

Name*

First NameMiddle InitialLast Name

Current US State Driver's License

DL State*

Enter full name of US state

DL Number*

Driver's License held in another COUNTRY (not the US)

DL Country*

Enter full name of country

DL Number (if available)

DL Issue Date*

Enter date you received DL from other country (not in US)

Answer the following questions about the driving history of your driver's license held in another country:

1. I have not been convicted of or pleaded guilty to any moving violations in the past three years, except (list all violations and dates; if none, write "none"):*

2. I have not been involved in a motor vehicle accident during the past three years, except (list the dates and location; if none, write "none"):*

3. I have not been convicted or pleaded guilty to any of the following offenses during the past three years: Leaving the scene of an accident; Reckless Driving; Any driving-related violations involving drugs or alcohol; Hit and run; Vehicular homicide or assault; Participating in an unlawful speed contest; Eluding or attempting to elude a law enforcement officer; Any other driving-related violations which could present a danger to the public, except (list all offenses and dates; if none, write "none"):*

I understand that you are relying on this information and state the foregoing is true and correct according to my best knowledge, information, and belief.

Date of Birth*

Date

Last 4 digits of Social Security Number*

Signature*