Release Of Interest Form printable pdf download

Attachment F

Release of Interest

Employee/Prospective Employee/Volunteer organization

American Driving Records, Inc. is acting as an agent on behalf of ______________________________ who is acting as an

agent on our behalf to obtain the abstract of driver records of the individual named below for employment

purposes.

This is an authorization of:

1. Employee for release of abstract of driving record for employment purposes, at my employer’s

discretion for the full term of my employment; or

2. Prospective employee for release of abstract of driving record for employment purposes, not to exceed

thirty (30) days from date signed; or

3. Volunteer for the release of abstract driving record for which the volunteer has submitted an

application for a position that would require driving by the volunteer at the direction of the volunteer

organization.

I, _____________________________________________, am an employee, prospective employee, or volunteer of the

company named below and I request a copy of my official Driving Record in the state of Washington be

released to my employer, prospective employer, or volunteer organization or their agent.

Employee/Prospective employee/Volunteer Full Name

WA driver license number or date of birth

Employee/Prospective employee signature

Date signed

The Company listed below agrees to, and shall indemnify and hold harmless the state of Washington,

Department of Licensing (DOL), the Director of DOL and all DOL employees from any and all suits at law or

equity, and from any and all claims, demands or loss of any nature, including but not limited to all costs and

attorney’s fees, arising from any incorrect or improper disclosure of individual names or addresses under this

“Certification of Use”; any defects in any of Subscriber’s procedures followed or omitted or arising from

failure of Subscriber or its officers, employees, customers, contractors or agents to fulfill any of its obligations

under this Contract; or arising in any manner from any negligent act or omission by Subscriber or its officers,

employees, customers, contractors, or agents.

I hereby certify:

1. The company named below is an employer, prospective employer, or volunteer organization of the

above-named individual.

2. That the information contained in the abstracts of driver records obtained from DOL shall be used in

accordance with the requirements and in no way violate the provisions of RCW 46.52.130. No

information contained therein will be divulged, sold, assigned, or otherwise transferred to any third

person or party. The abstracts of driver records shall be used exclusively for;

I affirm that I am a representative authorized to bind the named Company below

Company Name

Address

Authorized representative name

Title

_____________________________________________________________________________

Date and place signed

Authorized representative signature

NOTE: The employer or prospective employer must maintain this record for a period of not less than two (2) years from the date of

the most recent request. Failure to obtain signatures or misuse of records obtained from the State of Washington may result in

prosecution under RCW 46.52.130.

Release Of Interest Form

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