ROSE-HULMAN INSTITUTE OF TECHNOLOGY
RISK MANAGEMENT-STUDENT FORM
@DEPARTMENT REQUEST
Motor Vehicle Background Check
MVR INFORMATION:
Last Name: _________________________ First: _____________________Middle: _______________
Date of Birth: _____/_____/_____ Social Security #: ________________________________________
Driver’s License #: ______________________ State: ________________ Exp. Date: ____/____/____
Department: ____________________________ Building: ____________________________________
Department Supervisor Signature________________________________________________________
Rose-Hulman Institute of Technology requires all persons that may operate a RHIT vehicle or rental vehicle
provide RHIT with authorization to obtain a Motor Vehicle Report from the Bureau of Motor Vehicles (BMV) in
the state where the employee is licensed. By signing this form, you agree to allow the BMV to release information
to the appropriate Rose-Hulman personnel. This releases the aforesaid parties from any liability and responsibility
for collecting the above information.
I also hereby certify that this report request meets the definition of “permissible uses” of state motor vehicle
records under the provisions of the Drivers Privacy Protection Act of 1994 (Public Law 103-322, Title XXX,
Section 300002 (a)).
Student Signature ________________________________________ Date: _____/_____/_____
**This form is ONLY for student workers when approved by the department. **