Laserfiche WebLink
Page 8 of 8 <br /> City of <br /> Pequot Authorization and Consent for Release of Information <br /> Lakes= (Driver's License Record) <br /> The information you are being asked to provide will be used by the City of Pequot Lakes <br /> personnel to determine your qualification to drive vehicles on city business. You are not required <br /> by law to provide this information but if you do not do so you will not be approved to drive <br /> vehicles on city business. A refusal may result in your removal from employment with the City of <br /> Pequot Lakes. <br /> The information on this form will be accessible to your supervisor and other personnel who need <br /> the information for their assigned work. Your Driver's License Number may be used to obtain a <br /> driver's license record from the Driver and Vehicle Services Division for each state where you <br /> have held a driver's license in the past five years. <br /> (a) Driver's Name <br /> First Middle Last <br /> (b) Date of Birth <br /> (c) Driver's License Number <br /> (d) Issued by State of <br /> (e) Driver's Phone Number <br /> I, authorize the City of Pequot Lakes to obtain my driver's license record from any state wherever <br /> I have held a Driver's License in the last 5 years. I also understand that my driver's license record <br /> may be obtained and reviewed annually in conjunction with this Vehicle Fleet Safety Policy. <br /> I agree to update this Policy information in the event of a change to any of the data supplied above. <br /> I also agree to inform my supervisor in the event of license revocation, restriction, or suspension. <br /> I acknowledge that I have carefully read this release, fully understand its terms and legal <br /> significance, and execute it voluntarily. <br /> Executed this day of , 20 <br /> Signature of Individual Authorizing Release <br /> Signature of Witness <br /> S:\Sandy Documents\City Clerk\Policies\Fleet Policy\Vehicle Fleet Safety Policy-Revised 2015.doc <br />