Fillable USE FOR GEORGIA LICENSES ONLY Motor Vehicle Record (Kennesaw State University)

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USE FOR GEORGIA LICENSES ONLY Motor Vehicle Record (Kennesaw State University)

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USE FOR GEORGIA LICENSES ONLY
Motor Vehicle Record Form
If you previously submitted the MVR Authorization Form to Risk Management you DO NOT need
to resubmit a new form unless one of the following applies:
1. Information on your Georgia Driver’s License has changed since you submitted the original form
(name change or License Number change).
2. You obtained a new Georgia Driver’s License and surrendered your Out-of State License.
3. Your driver status has changed and you will operate a vehicle.
Please complete the Motor Vehicle Record Form, print, sign, and date where indicated. Send
the original form to KSU Risk Management via one of the following methods.
**If you are sending more than one (1) MVR form, please scan each form separately.**
**DO NOT INCLUDE THIS PAGE WHEN SCANNING **
1. Send via fax to KSU Risk Management’s secure fax line, 470-578-9325.
2. Kennesaw campus: Scan to the #DDS folder on a campus Ricoh device. See detailed instructions
for the 2 types of Ricoh devices here:
Ricoh with Other Functions Button or Ricoh with Home Button.
3. Deliver the original form in person in a sealed envelope to the Office of Insurance and Risk
Management, Kennesaw Campus, Chastain Point, Suite 109A.
4. If you do not have access to a Ricoh scanning device and cannot deliver in person, please send
the original form via U.S. Mail to:
Do not include this page when scanning or faxing
Office of Insurance and
Risk Management
Kennesaw State University
1000 Chastain Road
MD 3603
Kennesaw, GA 30144
** This form is only for employees with a GEORGIA driver's license. If you currently have an Out-
Of-State driver’s license, Human Resources will run your MVR. To submit an Out-of-State MVR
to HR please complete the following steps.
Please fill out the Out of State MVR Form and forward it to Human Resources via email to
backgrounds@kennesaw.edu. HR will input the information you provide into their
system and you will receive an automatic email from DoNotReply@talentwise.com.
This email will contain a link to complete the electronic background consent form. This
electronic process allows you to fill out the consent form on a secure website and sign with
an electronic signature.
***Please note...If you have an Out-of-State license and you are a resident of Georgia, you
must obtain a Georgia Driver’s License within 30 days of establishing residence.
(O.C.G.A. § 40-5-20).
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Office of Insurance and Risk Management
New / 1st Time Request ~OR~
Employee has submitted this form as a (SELECT ONE):
Name or License Number Change Request
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USE FOR GEORGIA LICENSES ONLY Motor Vehicle Record (Kennesaw State University)

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Completed 13 September 2021

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