Amazon Logistics Driver Record Authorization

dl WASHIN&TON STATE DEP RIMENI OF

• LICENSING

Driving Record

Release of Interest

Employers, prospective employers, volunteer organizations, or their agent can get driving records for an employee, prospective employee, or volunteer when authorized. Use this form to get their authorization.

• Complete the Company section.

• Give this form to your employee, prospective employee, or volunteer to complete their section.

• For audit purposes, keep this completed form in your files for at least five years. Do not mail it to the Department of Licensing.

Sealed juvenile records. Information contained in a driving record related to a sealed juvenile record may not be used for any purpose unless required by federal law. The employee or prospective employee may furnish a copy of the court order sealing the juvenile record to the employer, prospective employer, or their agent. PRINT or TYPE Company name

Amazon Logistics - Independent Contractor

Agent company name (if applicable)

Accurate

Company/Agent company address

Address ofAmazon Logistics, Inc.: 5214 1st Ave S, Seattle, WA 98108 Authorized representative name Title

Sean Thomas Mana er, Global Risk & Compliance

Answer the following

1. Is this company an employer, prospective employer, or volunteer organization of the individual whose driving record is being requested? Ill Yes D No 2. Is the record you are requesting necessary for employment purposes related to driving by the employee or prospective employee as a condition of employment or related to driving by the volunteer at the direction of the volunteer organization? Ill Yes No 3. Do you agree to use the information contained in the record exclusively for this purpose and not divulge it to a third party? Ill Yes D No 4. Do you agree to hold harmless the Washington State Department of Licensing for all matters relating to the release of the requested driving record? Ill Yes D No Certification

I declare under penalty of perjury under the law of Was • g.f Date and place (city or county) signed

Employee, prospective employee, or volunteer-Complete this section and return the form to the company PRINT or TYPE Full name (First, Middle, Last) I Date of birth (mmlddlyyyy) I WA driver license number Authorization from

Employee-for release of my driving record for employment purposes, at my employer's discretion for the full term of my employment

D Prospective employee-for release of my driving record for employment purposes, not to exceed 30 days from date signed

Volunteer-for release of my driving record for a position applied for that requires me driving at the direction of the volunteer organization

Employer, prospective employer, or volunteer organization name Amazon Logistics - Independent Contractor

Employer agent company name if acting on behalf of the company for employment purposes Accurate

Authorization

I am an employee, prospective employee, or volunteer of the company named above and I request that a copy of my Washington State driving record be sent to them/their agent. RCW 46.52.130

DSC-425-020 (R/5/19)WA

X

Signature Date

Seattle

Contact this candidate