DRIVING RECORD AUTHORIZATION FORM
Name: Date of Birth:
Driver s License #: State of Issue:
1. If you are under 21 years of age, have you been a licensed driver for at least Yes No N/A
two (2) years? (over 21)
2. Within the last three years, have you had any traffic violations or accidents? Yes No
If yes, explain in remarks, including date(s) and circumstances.
3. Have you ever had your license suspended or revoked? Yes No
If yes, explain in remarks, including date(s) and circumstances.
4. Have you ever been convicted of:
a. Driving under the influence of drugs or alcohol? Yes No
b. Leaving the scene of an accident? Yes No
c. Reckless Driving? Yes No
If yes, explain in remarks, including date(s) and circumstances.
As an applicant for employment at BAMSI whose duties may involve driving my own or agency
vehicles, I understand that a check of my driving record will occur through the Registry of Motor
Vehicles. The Philadelphia Insurance Company, which insures agency vehicles, will conduct this
check. An offer of employment may be rescinded if I am not approved as an authorized driver by the
insurance company. Once hired, failure to maintain a good driving record may result in reassignment to
a non-driving position (if available) or termination of employment.
Remarks:
Signature Date
Print Name
4/4/11