Authorization To Obtain Motor Vehicle Record

VA Code 46.208 classifies driver abstracts as privileged records and limits the release of an abstract of a driver’s record to only an employer, potential employer, or authorized agent who has been authorized in writing by such driver to obtain the driver’s record.

THE UNDERSIGNED DOES HEREBY ACKNOWLEDGE AND CERTIFY AS FOLLOWS:
1. That the undersigned gives his or her consent to the release
     of their driving record (“MVR”) for review by:
Name of Employer
or Potential Employer:		 ___________________________________________________
2. That the undersigned authorizes his or her driving record to be periodically obtained
     and reviewed for the purpose of initial and continued employment.
Name of Employee
or potential employee:

___________________________________________________
Print name as it appears on your Driver's License
License Number: ____________________________ State: ________________
Date of Birth: _____/_____/_____
Signature of employee
or potential employee: 		___________________________________________________
Date: _____/_____/_____

Please print out this form, complete all information, and fax it to us at 540-659-6565