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Rev: 02/2011 Motor Vehicle Record Evaluation Request
 

Summary: Rev: 02/2011
Motor Vehicle Record Evaluation Request
Complete Part I & forward to Risk Management in person (GEN Bldg. 585, Bay 17, Room 183) or by fax @ 713-743-8035
Part I Current Employee Job Applicant: Notify EHRM if hired
PLEASE PROVIDE INFORMATION AS IT APPEARS ON LICENSE
Name: ___________________________________________________________________________
Last First Middle
State: __________________ Driver's License Number: ____________________________________
Date of Birth: _______________ (mm/dd/yyyy) Expiration Date: ______________ (mm/dd/yyyy)
Contact Person: _______________________________ Ext: ___________________
Department: __________________________________ Campus Mail Code: __________________
Date of Request: _________ (mm/dd/yy) Contact Email: ___________________________________
Department Supervisor: __________________________ Signature: _________________________
NORMAL TURNAROUND FOR TEXAS MVR'S IS 3 DAYS (No Charge)
FOR OUT-OF-STATE SERVICE REQUESTS
THERE IS A NOMINAL FEE (Approx. $10) TO BE PAID BY THE REQUESTING DEPARTMENT.
Please have the employee read the following statement and sign where indicated
I hereby authorize the University of Houston to obtain and prepare an investigative consumer report as set forth above, as part
of its investigation of my employment application. This authorization shall remain in effect over the course of my employment.
Employee's Full Name: _______________________________ ________________________________________

  

Source: Azevedo, Ricardo - Department of Biology and Biochemistry, University of Houston

 

Collections: Biology and Medicine; Environmental Sciences and Ecology