DMI\Driver Record Checks\All MVR Forms\MVR Check Disclosure Sample Document 8-16 srh
Note to College: Give this form to, and obtain a signature from, the
applicant/employee/student/volunteer BEFORE asking DMI to obtain an MVR.
In compliance with the Fair Credit Reporting Act (FCRA), this Disclosure is provided to advise you that, subject to your
consent, Lakeshore Technical College will be requesting access to your MVR.
As a potential operator of a Lakeshore Technical College owned vehicle, or an individual driving any other motor vehicle
on behalf of the College, your MVR will be obtained from a third-party consumer reporting agency and provided to DMI.
No portion of your driving record will be released by DMI or the College. The College department requesting your
services as an operator of a College vehicle or any other motor vehicle for official College business will be advised on
your status as “acceptable” or “not acceptableper the DMI Driver Record Evaluation Procedure.
You have the right, upon written request made within a reasonable amount of time, to request whether a consumer
report has been run about you and to request a copy of your report. The scope of this Disclosure will allow the College
to obtain from any outside organization your MVR throughout the course of your employment, or volunteer or student
status to the extent permitted by law.
Kindly complete the section below
I am aware that MVRs may be obtained as part of Lakeshore Technical College’s evaluation of my driving record. The
report may be procured by Lakeshore Technical College or DMI representative(s), and may include personal information
obtained from state motor vehicle departments. An assessment of my status for operating a motor vehicle on behalf of
the College will be completed.
_____________________________________________________________ _____________________________________
Full Name (as it appears on driver’s license) Date of Birth
Signature of Employee/Applicant/Student/Volunteer
Requesting College Department:________________________
______________________________________________________________ ______________________________________
Signature of Department Representative Date
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