NORTH CAROLINA DIVISION OF MOTOR VEHICLES

Driver Privacy Protection Act Authorization

To Disclose Personal Information Form DPPA-2

I understand that personal information contained in my Motor Vehicle Record is protected by the federal Driver Privacy Protection Act and N.C. General Statue 20-43.1. I hereby authorize the release of my personal information to the person named below.

Erica Green - Affinity Clinical Services

5624 Executive Center Drive, Suite 105

Charlotte, NC 28212