Annual Renewal Declaration Form

"*" indicates required fields

Advised staff about driver's license

I attest that I have advised staff of South Central Cancer Resource if my driver's license has been suspended or restricted for any reason, if I became the subject of any criminal investigation, if I became the subject of child welfare investigations or if any charges were brought against me, even if the charges are pending.

Please check the appropriate line:

There have been no occurrences as described above since my last Police Record Check or Renewal Declaration Form.

I confirm that driver's license and vehicle registration remain unchanged.

I hereby attest that the information disclosed herein is true, complete, and accurate to the best of my knowledge and belief.

Full Name*

Signature*