CONSENT TO OBTAIN STATE MOTOR VEHICLE RECORDS
Select:
-
I ________(name of driver) NSU ID number ____Email address:
____________________understand that the Driver’s Privacy Protection Act of 1994 (18 U.S.C.A. § 2721)
prohibits the release and use of certain personal information from State motor vehicle records; however,
pursuant to 18 U.S.C.A. § 2721 (13), I hereby consent to permit NOVA SOUTHEASTERN UNIVERSITY to
obtain motor vehicle records from any State’s records annually. I understand and agree that if I am unable,
for any reason, to maintain a US valid driver’s license, with no more than 3 points, it may result in
disciplinary action up to and including termination of my employment with Nova Southeastern University.
I acknowledge that all drivers must notify their supervisor immediately following receipt of a license
suspension, citation or revocation. Accordingly, I further acknowledge and agree that any failure on
my part to immediately make such notification may result in disciplinary action up to and including
termination of my employment. For non- employee drivers it may result in losing driving privileges of Nova
Southeastern University vehicles.
1. My date of birth is:
2. My current driver’s license was issued in the State of:
# of years licensed in the current state (If less than 3 years
fill out # 5)
3. My current driver’s license number is:
(Please attach a copy of your driver’s license)
4. My address as it appears on my driver’s license is:
5. I have also held a driver’s license in the following state(s):
Driver’s license number is:
6. I have been charged with a violation of a motor vehicle law
in the following state(s):
X
Signature of person giving consent Date signed
DEPARTMENT:
Printed name and telephone extension of
Signature
of
responsible for
Email addresses of Risk Management staff
guimarae@nova.edu and ealexand@nova.edu
Elizabeth Guimaraes and Alexandra Epstein
*Both MVR Consent Form and NSU MVR spreadsheet must be completed and emailed*
click to sign
signature
click to edit
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click to sign
signature
click to edit
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