University of San Diego
TO: Risk Management Department MH-101Date: _______________ University of San Diego _____________________________________ Will Drive For__________________________ Print Full Name Department RE: Authorization to Obtain Motor Vehicle Reports ____________________________________________________________________________ I am aware that motor vehicle reports may be obtained as part of USD’s evaluation of my job application and/or employment and/or authorization to drive a USD vehicle. The reports may be procured by USD, its broker of record or its insurance company representative(s), and may include personal information obtained from state motor vehicle departments, my driving record, and an assessment of my insurability for the insurance program. By signing this form, I hereby provide my authorization for USD or their representative(s) to procure such information and reports, from time-to-time as deemed appropriate, to evaluate my insurability. Details regarding insurability can be found on the Vehicles and Travel – Domestic page of the Risk Management website.Please Print the Following Information Full Name as it appears on Driver License: _____________________________________ E-mail Address: ____________________________________@_____________________________ Phone #:________________________Date of Birth:__________________________ (mm/dd/yyyy) Driver License Number : _________________________ State Issued: ___________________ License Expiration Date:_______/________/20______(mm/dd/yyyy) __________________________________________________ __________________________ SIGNATUREDATE SIGNEDNote: You will receive an email from TrueScreen. You must respond to the email for your record to be checked.March 2016 ................
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