I acknowledge receipt of the separate documents titled, “MOTOR VEHICLE RECORD (MVR) CHECK DISCLOSURE,” and
certify that I have read and understand this document.
I understand that, as a condition of my employment or authority to drive a motor vehicle on behalf of Lakeshore
Technical College, I hereby authorize Lakeshore Technical College to obtain my MVR at any time after receiving this
signed form and throughout my employment, or volunteer or student status.
I hereby consent to, and authorize, Lakeshore Technical College requesting any and all motor vehicle records from DMI.
I agree that a facsimile (“fax”), electronic or photographic copy of this form shall be as valid as the original.
I understand that, pursuant to the federal Fair Credit Reporting Act, Lakeshore Technical College will provide me with a
copy of any such MVR report if the information contained in such report is, in any way, to be used in making a decision
regarding my fitness for employment, continued fitness for employment, or authority to drive on behalf of Lakeshore
Technical College.
If applicable, I further understand that such report will be available to me prior to any such employment decision being
made, along with the name and address of the reporting agency that produced the report.
Kindly complete the section below
1. I have held a driver’s license issued from the state of Wisconsin and no other state throughout the past 6 years.
2. I have held a driver’s license issued from a state other than Wisconsin within the past 6 years.
3. Other than Wisconsin, I have held a driver’s license in the following states (list states):
4. Out-of-State License Holder Affidavit Form requested/completed.
5. I am (check one):
an employee (or an applicant for employment) of the College.
a student (course requirement to operate vehicle).
a student (not for a course requirement [e.g., volunteer/driver for a fieldtrip, conference, etc.]).
a volunteer of the College (e.g., volunteer/driver for a fieldtrip, conference, etc.).
__________________________________________________________ ___________________________________
Name (as it appears on driver’s license) Date of Birth
Wisconsin Drivers License Number:________________________________________
Page | 2
Other State Driver’s License Number(s):_____________________________________________________________________
Current mailing address of Employee/Applicant/Student/Volunteer
Signature of Employee/Applicant/Student/Volunteer
Requesting College Department:__________________________________
________________________________________________ ____________________________
Signature of Department Representative Date
DMI\2016\Consent and Auth For MVR CHECK - JMG 3-17-1
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