[City of Pocatello] Driving Record Release Form

Driving Record Release Form

I hereby authorize the City of Pocatello to review my driving record, and I authorize the Department of Motor Vehicles and any other agency or government entity with driving information to release their records to the City of Pocatello.

I understand this is a job-related requirement as I may/will be operating City vehicles if employed. I also understand that during my employment with the City, periodic checks will be made on my driving record, and I authorize the same. I understand that any convictions or plea of guilty for Driving Under the Influence of Intoxicants or Reckless Driving, on or off the job, or loss of full driving privileges may result in dismissal of my employment with the City of Pocatello, whether or not a withheld judgment is given.

Listed below are any moving violations I have received in the last three (3) years:

Moving Violations

Violation #1

Date

Violation

Was on an interstate highway?

Violation #2

Date

Violation

Was on an interstate highway?

Violation #3

Date

Violation

Was on an interstate highway?

Violation #4

Date

Violation

Was on an interstate highway?

Driver Information

Phone Number

Date of Birth

Driver's License State

Driver's License Number

Social Security Number

Acknowledgement

Accuracy of Information

If the above information is not accurate, I understand that it will be considered cause for immediate dismissal if I am hired.

Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.