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MVR / Driver Record Consent Form
I hereby authorize JASNA EXPRESS INC, and its designated agents and representatives to conduct a comprehensive review of my driver record background through a consumer report (MVR) and/or an investigative consumer report to be generated for insurance purposes. Upon Request, JASNA EXPRESS INC will supply a copy of the completed consumer report along with a copy of an individual’s rights under the Fair Credit Reporting Act.

Authorization and Release
I (driver’s name), authorize the complete release of these records or data pertaining to me which an
individual, company, firm, corporation, or public agency may have. I authorize the full release of the information described above, without any reservation, to any insurance company used by JASNA EXPRESS INC. I hereby release JASNA EXPRESS INC and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization for release form. I certify that all information provided below and on my insurance application is correct to the best of my knowledge. This authorization and consent shall be valid in original, fax, or copy form. The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose.

Notice to California Applicants: Under section 1786.22 of California Civil Code, you have the right to request from Embark Safety LLC, upon proper identification, the nature and substance of all information in files pertaining to you, including the sources of information, and recipients of any reports on you, which Embark Safety LLC has previously furnished within the two-year period preceding your request. You may view the file maintained on you by Embark Safety LLC during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a written request, you may receive a summary of your report.
Notice to Maine Applicants: Under Chapter 210 Section 1314 of Maine revised Statutes, you have the right, upon request, to be informed within 5 business days of such a request to whether or not an investigative consumer report was requested. If such report was obtained, you may contact the Consumer Reporting Agency and request a copy.
Notice to Massachusetts Applicants: Under Mass. Ann. Laws chapter. 93 §§ 50, a Consumer Reporting Agency may furnish a report if intended to be utilized for employment purposes.
Notice to New York Applicants: Under Article 25 Section 380-c (b) (2) of the New York General business Law, you have the right, upon written request, to be informed of whether or not an investigate consumer report was requested. Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses.

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