DMV RECORD RELEASE
If the position for which you are applying requires a Driver’s License, please provide the information below so that we may obtain a copy
of your driving record.
PLEASE PRINT CLEARLY
.
Last Name
First Name
Middle
Driver’s License Number
PRIVACY ACT NOTICE FOR EMPLOYMENT FORMS
NOTICE TO APPLICANTS
This information is provided pursuant to the Privacy Act of 1976 for individuals supplying information for inclusion
in a system of records.
POLICY
The policy of the City of Hampton is to collect, maintain, use and disseminate only the personal information
required by law to accomplish a proper purpose.
PURPOSE, USE, ACCESS, AND DISSEMINATION
Information furnished will be used primarily by City departments/divisions and agencies to determine
qualifications for employment, eligibility for transfer, reinstatement, promotion and/or demotion. All or part of
this information may be furnished as indicated below:
1. Representatives from City agencies, if required to determine employment suitability.
2. Federal, state and local agencies in which you have interest as a potential employee.
3. Federal, state and local agencies to create personnel files following your employment with the City of Hampton.
4. Representatives of federal, state and local agencies engaged in investigating violations of the law.
5. Individuals or agencies requesting statistical data exclusive of personal identification.
6. Requesting agencies possessing your voluntary release of information and assuming confidential protection of
information released.
EFFECTS OF NONDISCLOSURE
It is in your best interest to answer all questions. Your failure to complete the form may jeopardize your
opportunity for employment.
DISCLOSURE OF SOCIAL SECURITY NUMBER
The Social Security Act of 1976 provides for soliciting social security numbers, and disclosure on your part is
mandatory to obtain the benefits you are seeking.
CERTIFICATION/AGREEMENT
I have read and understand the above DMV Record Release and Privacy Act Notice For Employment Forms. I hereby
certify that this application is a complete record and that all entries and all attachments are true and accurate to the best
of my knowledge. I understand that false or incomplete statements herein supplied are grounds for disqualification
from employment consideration or termination of employment. I authorize the City of Hampton to conduct a
thorough background investigation, except as it pertains to race, origin, sex, age, or other non-job related criteria, to be
used relative to my employment with the City of Hampton. I authorize my former employers and any other persons or
organizations to provide any information they have about me, and I release all concerned from any liability in
connection therewith. If permanent employment is offered, I understand that I may be required to pass an examination
given at the City’s expense, and that my employment may be contingent upon successfully passing that examination.
I release the City of Hampton and any individual or entity providing information to the City of Hampton from all
liability for any damages from the disclosure of this information.
APPLICANT’S SIGNATURE
DATE (Month/Day/Year)
How were you referred to the City of Hampton?
Job Fair
Newspaper
Trade Publication
Employment Agency
Other
City of Hampton Employee: Name
