Skip to content
(415) 456-9062
|
Contact Us
|
Healthy Aging Campus
(415) 456-9062
|
Contact Us
Donate
Class Schedule
Café Menu
Search
Home
About
About Us
Who We Serve
News Room
Leadership Team
Board of Directors
Mission and Values
Our History
Awards
Community Partners
About our Name
Financials
Rent Our Facility
Services
Rides
Rides
Assisted Rides & CarePool Free Volunteer Rides
Medical Rides
Business Services
Meals
Meals & Nutrition
Meals on Wheels
Nourish Home-Delivered Meals
Jackson Café
Brown Bag Pantry
Monthly Food Box
Classes
Classes & Activities
Calendar
Partner Classes
Lifelong Learning
Healthy Aging
Community Lounge
Become a Member
Rent Our Facility
Care
Advice
Employment
Jobs at Vivalon
Drive for Vivalon
Employment Application
Volunteer
Volunteer at Vivalon
Volunteer Application
Ways to Support
Donate
Ways to Support
Employee Giving
Donor Advised Funds
Charitable IRA
Stocks and Mutual Funds
Donate Your Vehicle
Leadership Circle
Planned Giving
Sponsorships
Special Events
Wish List
Financials
Menu
Home
About
About Us
Who We Serve
News Room
Leadership Team
Board of Directors
Mission and Values
Our History
Awards
Community Partners
About our Name
Financials
Rent Our Facility
Services
Rides
Rides
Assisted Rides & CarePool Free Volunteer Rides
Medical Rides
Business Services
Meals
Meals & Nutrition
Meals on Wheels
Nourish Home-Delivered Meals
Jackson Café
Brown Bag Pantry
Monthly Food Box
Classes
Classes & Activities
Calendar
Partner Classes
Lifelong Learning
Healthy Aging
Community Lounge
Become a Member
Rent Our Facility
Care
Advice
Employment
Jobs at Vivalon
Drive for Vivalon
Employment Application
Volunteer
Volunteer at Vivalon
Volunteer Application
Ways to Support
Donate
Ways to Support
Employee Giving
Donor Advised Funds
Charitable IRA
Stocks and Mutual Funds
Donate Your Vehicle
Leadership Circle
Planned Giving
Sponsorships
Special Events
Wish List
Financials
Motor Vehicle Records Authorization
If my relationship with Vivalon will involve driving my own vehicle or a company vehicle on behalf of Vivalon, I hereby authorize Vivalon’s insurance company and/or Heffernan Insurance Brokers to be in possession of my driver’s license number, obtain the necessary motor vehicle records and authorize them to send a copy of my Motor Vehicle Record to Vivalon. I understand the insurance broker and the insurance company writing the driving insurance requires my driver’s license number and information in order to assess my insurability by running a Motor Vehicle Record (MVR) report. I also understand that I have the right to see a copy of my MVR upon request. This authorization will be valid until such time I finish my drivers' training or Vivalon.
*Please print your full name
(Required)
Last Name
First Name
Middle Name
Driver's License Number
(Required)
Driver's License State
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date of Birth
Month
Day
Year
Signature
(Required)
Date
(Required)
Month
Day
Year
Electronic Signature Consent
(Required)
You consent to signing this document electronically.
Δ
Enable JavaScript to ensure
website accessibility
Scroll to Top