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)
MM slash DD slash YYYY
Electronic Signature Consent(Required)
MM slash DD slash YYYY

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