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.