Apply Online – Driving Record Verification Driving Record Verification Section 1: To be completed by authorized human resources staffI hereby request the Department of Motor Vehicle to release to VNA & Hospice of the Southwest Region information involving the individual listed below in Section 2. I certify that this individual is a current employee of this company or has been given a conditional offer of employment. I understand this information is only for the purposes of offering employment and agree it shall be otherwise kept confidential. Signature of authorized Human Resources staffDateSection 2: To be completed by applicant: Consent from current or prospective employeeName* First Middle Last Date of Birth*Operator's License Number*State of Issue*Expiration Date*I currently possess a valid driver’s license. I have not received a conviction violation or involvement in an accident, nor have I had my license suspended at any time during the past three years, other than the following:I hereby authorize the Department of Motor vehicles to release to VNA & Hospice of the Southwest Region any information relating to my driving record. I certify that I am currently employed by the above named company or have been given a conditional offer of employment by the company.(Prospective) Staff Signature*Date*EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.