FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604

- FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
- REQUEST FOR CHECK OF DRIVING RECORD

Applicant's Full Name
Address
City	State
Zip Code
Phone Number
Date of Birth
License Number
Social Security #
Company Supervisor Name
YES as the representative of this company, I am attesting that the above information is necessary to determine if the licensee can be employed, or remain employed, as a commercial driver on public roadways. I am hereby authorizing my safety director or insurance agent to obtain any or all of the above information on this companies behalf. This form shall be kept on file for a minimum of five years.

REQUESTED BY
MOTOR CARRIER COMPLIANCE & SAFETY CO 104 W. Water Street OAK HARBOR, OH 43449 (419) 898 1570