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Menu
Home
About
About Us
70th Anniversary
Who We Serve
News Room
Voices@Vivalon Blog
Our Team
Executive Leadership
Board of Directors
Fundraising and Marketing
Mission and Values
Our History
Awards
Community Partners
About our Name
Financials
Rent Our Facility
Rides
Rides
Assisted Rides & CarePool Free Volunteer Rides
Medical Rides
Business Services
Title VI Civil Rights Policy
Meals
Meals & Nutrition
Meals on Wheels
Nourish Home-Delivered Meals
Vivalon Café
Brown Bag Pantry
Monthly Food Box
Programs
Class Schedule
Healthy Aging Campus
Healthy Aging Programs
Arts & Community Activities
Health & Wellness Classes
Technology for Better Living
Educational & Experiential Offerings
Cowles Active Learning Program
Resources
Become a Member
Rent Our Facility
Employment
Jobs at Vivalon
Volunteer
Volunteer at Vivalon
Volunteer Application
Ways to Support
Donate
Ways to Support
Donate Monthly
Donate Your Vehicle
Planned Giving
Donor Advised Funds
Charitable IRA
Stocks and Mutual Funds
Leadership Circle
Special Events
Employee Giving
Sponsorships
Wish List
Financials
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
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You consent to signing this document electronically.
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