Federal Drivers Privacy Protection Act

Authorization to Obtain Motor Vehicle Report

For the sole purpose of the determination and evaluation of my motor vehicle operating record and pursuant to the State and Federal regulations of compliance, I (Name of Employee) ______________________________________________________ authorize Harding Brooks Associates LLC to obtain my Motor Vehicle Record for insurance underwriting/eligibility purposes . I understand that this record may contain personal information* in addition to any/all driver violations and/or accidents, which may be on record through the Department(s) of Motor Vehicles.

I also authorize release of this insurance underwriting/eligibility information to my employer. (or proposed employer.)

______________________________________________________

Signature of Employee (or potential employee)

Name (Printed): ______________________________________________________

Drivers License Number: _______________, State: _______________, Date of Birth: _______________

______________________________________________________

Street Address & Mailing Address

City: __________________, State: __________________, Zip: __________________

Date Signed: ______________________________________________________

*Personal information means information that identifies an individual including an individual’s photograph, driver identification number, name, address and telephone number.