Driving History Questionnaire and DMV Check

Driving Motor Vehicle Check Form

Form to attest to driving violations and authorize DMV check.

First Name*
Middle Name*
Please type full name not just an initial. If you do not legally have a middle name, type “no middle name”
Last Name*
This field is hidden when viewing the form
Legal Name
First Middle Last Suffix
Location*
Supervisor*
Social Security Number*
Date of Birth*
Month
Day
Year
Email*
Drivers License Number*
Driver's License State*
State
Expiration Date*
MM slash DD slash YYYY
Any other names used like maiden name, alias, etc.
Current Address*
Street Address Address Line 2 City State ZIP Code
Driving History
Is your license now revoked or suspended?*
- Yes
- No
If you marked yes, please explain why:
Have you been charged with any Type A or Type B violations in the last three (3) Years?
- Yes
- No
Type A Violations:
List all Type A violations along with the date and city/state where they occurred.
-Driving under the influence of alcohol or drugs -Refusing to take a substance test -Driving with an open container (alcohol) -Reckless driving or careless driving -Hit and run -Fleeing or evading police or roadblock -Racing speed contest -Driving on a suspended or revoked license -Vehicular assault
List B Violations
Please list all Type B Violations along with the date and city/state where they occurred.
-Moving violations that include-Speeding, Improper lane change, failure to yield, failure to obey a traffic signal or sign -Accidents -Having a license suspended related to a moving violation
Notification Required*
I agree to the driving motor vehicle check
You are required to notify your immediate supervisor and Human Resources, within 24 hours, if your license is revoked or suspended for any reason.

This authorization and consent for release of personal information acknowledges that Stan Clark Cos., Inc. (Hereafter referred to as “Company”) and/or its agent, Investigative Concepts, Inc., may now, or at any time while I am employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, state driving records; criminal history information on file in local, state or federal agencies; and motor vehicle records.

I understand that these searches will be used to determine work assignment or employment eligibility under the Company’s employment policies. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the Company. In addition, I release and discharge the Company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. After reading this document, I fully understand its contents and authorize the verification.

The undersigned certifies that all information provided above is correct and truthful. Any falsification of information or failure to comply with the mandatory regulations may result in disciplinary action, up to and including termination.
Signature*
Today's Date*
MM slash DD slash YYYY