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MVR Release Consent Form
Department: WakeMed Cary Volunteer Services
In connection with my application for employment and my ongoing employment or my duties as a contract worker or volunteer with WakeMed, I understand and agree that: (1) driving a company vehicle and/or my personal vehicle is a requirement of the position and (2) having and maintaining a satisfactory driving record is a condition of my employment. I expressly agree to allow WakeMed to obtain and review my personal driving record prior to my hire and periodically thereafter. I further agree to report to my supervisor immediately any license suspensions, serious traffic accidents or offenses, or any other condition that may affect my ability to drive for WakeMed.
I also agree to release WakeMed, its’ employees, and those who supplied the company with the information from any liability for any damage that may result from furnishing the requested information or my failure to be hired for the position for which I am applying.
Name
*
First
Middle
Last
North Carolina Driving License Number
*
Must Have a Valid NC. Drivers License
Date of Birth
*
MM
/
DD
/
YY
Todays Date
*
MM
/
DD
/
YY
Signature
Clear
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