Form Dsc-425-020 - Abstract Of Driving Record Release Of Interest
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1Abstract of Driving Record
Release of Interest
Employer, prospective employer, or volunteer organization name:
Agent business name if acting on behalf of the company for employment purposes:
This is an authorization of:
1. Employee – for release of my driving record for employment purposes, at my employer’s discretion
for the full term of my employment; or
2. Prospective employee – for release of my driving record for employment purposes, not to exceed
30 days from date signed; or
3. Volunteer – for release of my driving record for a position applied for that requires me driving at the direction of
the volunteer organization.
I,
, am an employee, prospective employee, or volunteer of
Your name
the company named above and I request a copy of my official driving record in the state of Washington to my
employer, prospective employer, volunteer organization, or their agent.
No employer, prospective employer, or their agent may use information contained in a driving record related to the
sealed juvenile record of an employee or prospective employee for any purpose unless required by federal law. The
employee or prospective employee must furnish a copy of the court order sealing the juvenile record to the employer,
prospective employer, or their agent.
Employee / Prospective employee / Volunteer full name (First, Middle, Last)
Date of birth (mm/dd/yyyy)
WA driver license number
Employee / Prospective employee / Volunteer signature
Date signed
X
The company listed below agrees to, and shall indemnify and hold harmless the state of Washington, Department
of Licensing (DOL), the DOL Director, 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 “Release of Interest;” any defects
in any of Company’s procedures followed or omitted or arising from the failure of Company 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 the company 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. 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 employment, prospective employment or a volunteer organization position.
I affirm that I am a representative authorized to bind the company named below.
Company name
Authorized representative name
Title
Address
X
Date 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 request. Failure to obtain all signatures or misuse of records obtained from the State of
Washington may result in prosecution under RCW 46.52.130.
DSC-425-020 (R/11/17)E
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