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2. 
4. Background and Driver's Record Check Release Form
6. Date
   Date
7. Department/Agency
9. First Name
10. Middle Name
11. Last Name
13. Phone/Cell Number
14. Email Address
16. Birthdate
    Birthdate
17. Driver's License Number
18. Race

    1. Alaska Native
    2. American Indian
    3. Black or African American
    4. Hispanic or Latino
    5. Native Hawaiian
    6. Other Pacific Islander
    7. White
19. Gender

    1. Male
    2. Female
21. Emergency Vehicle Operation Standards
    • License must not be suspended or revoked;
    • Minimum of 36 months licensed driving experience;
    • No DUI/DWI or reckless driving convictions within the past 36 months
    • No convictions for operating a vehicle during a period of license suspension or revocation within the last 36 months;
    • No convictions for Hit and Run, Negligent Homicide or Aggravated Assault from the use of a motor vehicle;
    • No convictions for use of a motor vehicle for the commission of a felony;
    • No more than two (2) moving violations within the past 36 months;
    • Must have successfully completed EVOC, Equipment Use and Maintenance Training as well as any ongoing training as required by insurer and/or state agencies.
22. Campbell County Public Safety Driving Criteria
    Click Here to Review
24. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that: 

    • 1) your submission will not be signed in the sense of a traditional paper document;
    • 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature; and 
    • 3) you may still be required to provide a traditional signature at a later date.

    Further, by checking the "I agree" box, you indicate that you have reviewed the Campbell County Public Safety Driving Criteria guidelines, and give the department permission to conduct/request a background investigation, including a criminal and driving record check for possible criminal or traffic violations and license status.

    *If submission is for someone under the age of eighteen (18) a parent/legal guardian signature is required.

    1. I agree.
26. Electronic Signature*
27. Parent/Legal Guardian Electronic Signature
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field