MVR Consent Form

I, the Proposed Applicant listed below, hereby acknowledge that, in connection with my application as an Independent Contractor, Indiana Transport, Inc. will procure a Motor Vehicle Report (MVR) on me as part of their consideration of my application and to determine whether I meet its risk management standards for insurability on their commercial auto insurance policy. In the event that information from the report is utilized in whole or in part in making an adverse decision, Indiana Transport, Inc. will upon my request cause to have mailed to me, by U.S. first class mail to the address on my driving record, a copy of the MVR which has been utilized. I understand that I have the right to request in writing within a reasonable time that Indiana Transport, Inc. make a complete and accurate disclosure of the nature and scope of the information requested.
This release and authorization shall remain valid and in effect for the duration of my lease agreement with Indiana Transport, Inc. its affiliates and/or its subsidiaries. Indiana Transport, Inc. reserves the right to run subsequent MVR’s on me as Indiana Transport, Inc. in its sole discretion determines is necessary.
I may revoke this Authorization at any time, provided that the revocation is in writing, except to the extent that Indiana Transport, Inc. has taken actions relying on this Authorization. If I proceed with such revocation of this Authorization, I will send a written revocation to Indiana Transport, Inc. at their address at which this application has been made.
By signing below, I hereby authorize Indiana Transport, Inc. and its affiliates or subsidiaries to obtain a Motor Vehicle Report about me in order to process my application as an Independent Contractor by evaluating my driving insurability on their commercial auto insurance policy. In addition, I also authorize all entities having information about me, including departments of motor vehicles, to release such information to Indiana Transport, Inc. and its affiliates or subsidiaries.
Signature
Clear
Date
First Name (Typed)
Middle Initial
Last Name (Typed)
Date of Birth
Cell Phone #
Drivers License #
State