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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.

___________________________________________________________

                    (Signature)                                                                                

 (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

                                         email:  smalleyofice@sbcglobal.net