MVR Consent and Information Form

ABILENE CHRISTIAN UNIVERSITY
MOTOR VEHICLE REPORT CONSENT AND INFORMATION FORM
EMPLOYEES
(initial here)
I understand and agree that in connection with my continued employment with Abilene Christian University ("ACU"), ACU
needs to obtain motor vehicle record (MVR) information to confirm my eligibility or continued eligibility to drive ACU vehicles
(whether owned, leased, or rented) or my personal vehicle in the course and scope of my employment. I understand that
ACU has an established MVR review program and that my driving history will be reviewed to determine my driving eligibility.
VOLUNTEERS
(initial here)
I understand and agree that ACU needs to obtain motor vehicle record (MVR) information as a prerequisite to determine my
eligibility to drive ACU vehicles (whether owned, leased, or rented) for ACU-sponsored activities. I understand that ACU has
an established MVR review program that my driving history will be reviewed to determine my driving eligibility.
ALL DRIVERS
'(initial here)
I understand and agree that ACU may use an outside agency to research my motor vehicle and driving records and that the
outside agency will provide an MVR report to ACU. Under the provisions of all applicable federal, state and local laws, I
hereby authorize and permit ACU, without reservation, to obtain an MVR from any and all states in which I have held a
driver's license. I also understand that ACU will comply with all applicable laws and will not release or distribute any MVR
information to any outside parties unless legally obligated to do so. I agree that a copy or facsimile of this authorization shall
be valid as the original. This authorization shall remain on file and shall serve as an ongoing authorization for ACU to obtain
my MVR for lawful purposes at any time during my affiliation with ACU unless revoked in writing. I further understand that
under the provisions of the Fair Credit Reporting Act, I have the right to receive a copy of the MVR report from ACU if the
results preclude that I am not insurable and that I will be given three (3) business days to dispute any inaccurate information. I
also understand that I must provide conclusive proof of inaccuracy and that disputing the results may not necessarily impact
the final determination.
I hereby agree to release, indemnify and hold harmless any person, firm or entity that discloses matters in
accordance with this authorization, as well as ACU, its employees, agents and representatives, from any and all
liability or damages of whatever kind or nature, whether known or unknown, which may at any time arise or result
from the request for use of and/or disclosure of any information pursuant to this authorization, except to the extent
that such liability or damages arises or results from a violation of any applicable law.
I understand and agree that I am responsible for reviewing and complying with the University Driver Policy and Procedures.
DRIVER INFORMATION
Please indicate applicable category: Faculty
Department/Organization
Staff
Student
Volunteer
Email Address
Print Full Name
Signature
Date
Supervisor/Sponsor
Signature
Date
Please attach a photocopy of your current Driver’s License to this form.
Return Form to:
ACU Office of Risk Management
Office: 325-674-2363 / Fax: 325-674-2396 / Email: [email protected]
6/15/2011