Document Sample
AppendixA Powered By Docstoc
					                                                                                                  Reviewed Nov 2008

Commercial Driver Abstract Authorization
                                                                                                 2260 – 11th Avenue
                                                                                                 Regina, SK S4P 2N7

I, the undersigned driver, hereby authorize Saskatchewan Government Insurance to disclose all information
concerning my driving record including convictions, motor vehicle accidents and my driving status to:

Company Name: ___________________________ Contact Name: _______________________________

Phone Number: _____________________

There is a ten dollar ($10) fee for each abstract requested. Payment must be received with request. Payment
may be made by cheque or money order, payable to SGI and mailed to the address below or by Visa or
Master Card when faxing your request.

Visa or Master Card Number: _______________________________ Card Expiry Date: ______________

Driver Information: Driver/plate record will not be released without the driver’s authorized signature.
       Driver’s Full Name        Date of Birth   Driver’s Licence No.         Driver Signature            DD/MM/YY

Driver/Plate Records are issued for a minimum of 5 years. Customers/Companies may request a record for a longer
period of time dating back to January 1995. Please indicate the number of years required ________.

Date of Request (must be completed): ____________________________________
                                             Day          Month        Year

                Mail Request To:                                 Fax Request To:
                Saskatchewan Government Insurance                Saskatchewan Government Insurance
                Driver Abstracts                                 Driver Abstracts
                2260 – 11th Avenue
                Regina, Saskatchewan                             306-775-6681
                S4P 2N7

3518                                                                                                       03/2007

Appendix A – Commercial Driver Abstract Authorization

Shared By:
Description: safety