MOTOR VEHICLE RELEASE AUTHORIZATION
By signing below, I hereby give my permission and authorization for the City of Groton to
obtain a copy of my motor vehicle record (through its insurance agent/broker/consultant).
The information obtained will be used for company insurance, safety, loss control, job
qualification, and/or compliance purposes. If hired or if currently employed, this release
and authorization will remain in effect during the term of my employment.
The City of Groton reserves the right to run subsequent motor vehicle reports on an
as needed basis.
_______________________________ _______________________
FIRST, MIDDLE AND LAST NAME DATE OF BIRTH
______________________________ _______________________
DRIVER’S LICENSE NUMBER STATE ISSUED
______________________________ _______________________
SIGNATURE DATE
This form will be retained in the employee’s personnel file
Updated 1-2-19
