Request for Check of Driving Record

I hereby authorize you to release the following information to

for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1 of Public Law 104-208), I hereby certify the following:

1. The consumer (applicant) has authorized in writing the procurement of this report.
2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes.
3. The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no other purpose.
4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation.
5. Before taking an adverse action based in whole or in part on the report, the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.

I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Sections 300002(a)).

DEAR SIR/MADAM:

REQUESTED BY: