Motor Vehicle Records Authorization

Driver License 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)

Date of Birth(Required)

Electronic Signature Consent(Required)

You consent to signing this document electronically.

Signature(Required)

Date(Required)

Healthy Aging Center
930 Tamalpais Ave.
San Rafael, CA 94901
415-456-9062

M-F 9am – 5pm

Vivalon Rides
15 Jordan St.
San Rafael, CA 94901
415-454-1098
Daily 8am – 5pm