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PRE-ADVERSE ACTION NOTICE

Date

Applicant/Employee/Student/Volunteer

Address

City, State Zip

Email addressCONFIDENTIAL – TO BE OPENED BY ADDRESSEE ONLY

RE:Eligibility to Drive on Behalf of Blackhawk Technical College

Dear Applicant/Employee/Student/Volunteer:

Blackhawk Technical College’s insurance company, Districts Mutual Insurance (DMI), indicates your Motor Vehicle Record (MVR) is unacceptable per its Driver Record Evaluation Procedure. As a result, Blackhawk Technical Collegemay make an adverse decision based, in whole or part, on the MVR. This notice informs you of certain information pursuant to the Fair Credit Reporting Act (FCRA).

Attached is a Summary of Your Rights Under the FCRA.

The MVR was procured pursuant to a Consent and Authorization form signed by you on [date].

Blackhawk Technical Collegedid not receive a copy of the MVR, so is unable to provide you with specific reasons for any MVR-related decisions to be made.

To obtain a copy of the MVR complete the attached form, “Authorization for Release by DMI of Motor Vehicle Record (MVR)” and email it to Suzette Harrell at . You may, but are not required toBlackhawk Technical Collegea copy of the MVR.

If you have any questions regarding the MVR, or believe it may contain incorrect information, you may dispute the accuracy or completeness of the information by contacting the Consumer Reporting Agency which provided the report(s), and they will respond to your inquiry.

The MVR providers’ contact information is as follows:

For Wisconsin-only MVRs:All other states MVRs:

Wisconsin Department of TransportationVerified Credential, Inc.

Bureau of Driver Services20890 Kenbridge Court

4802 Sheboygan AvenueLakeville, MN 55044

Madison, WI 53705Toll Free: 800-473-4934

Phone:608-264-7447Phone: 952-985-7200

Email: ax: 952-985-7218

Website Portal:

The above-entities only provide MVRs to our insurance company, DMI, and play no part in the decision to take any action on your status as someone driving on behalf of Blackhawk Technical College.

Sincerely,

Technical College Representative

Attachments:Summary FCRA Rights

Authorization for Release by DMI of MVR