Smalley Insurance Agency, Inc.
Smalley Insurance Agency, Inc.

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MVR Consent Form- pdf.pdf
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MVR Consent Form






I  ___________________________________________________ hereby authorize the Smalley Insurance Agency, Inc.,  1640 S. Rock Road, Wichita, KS 67207 to obtain a Motor Vehicle Report (MVR) .



   My Drivers License # is: ___________________________ 

                                State: _________


    My Social Security Number is:  _________________________


    My Date of Birth is:  _________________   




I understand that this report will provide information that may be used for employment and/or insurance purposes and that this information may be released to my employer.







 (Date) ____________________





                   (Street Address)




                  (City, State, Zip)




Return to:


Smalley Insurance Agency, Inc.             FAX:  (316) 685-5717

1640 S. Rock Road                              Phone:  (316) 687-2288

Wichita, KS 67207                           Toll Free:  (877) 682-8407





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© Michael Smalley