Application Driver Record Form – Fill Out and Use This PDF

MAIL TO: Texas Department of Public Safety, Box 149008, Austin, TX 78714-9008

	Check Type of Record Desired						FEE
	|	|	1.	Name – DOB – License Status – Latest Address.		$		4.00
|		|	2.	Name – DOB – License Status – 3 Year Record only lists Crashes/Moving Violations.		$		6.00
	|	|	2A. CERTIFIED version of #2. This Record is Not acceptable for a Defensive Driving Course (DDC).			$ 10.00
	|	|	3.	Name – DOB – License Status – Record of ALL Crashes/Violations. Furnished to Licensee Only.		$		7.00
|		|	3A. CERTIFIED version of #3. Furnished to Licensee Only and is Acceptable for DDC.			$ 10.00
|		|	Other: (Original Application, DWLI, etc.) | | | | | | | | | | | | | | | | | | |			$ | |		|.00
						(If Required)

Mail Driver Record To: (Please Print or Type)

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Requestor’s Last Name

Requestor’s First Name

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Street Address

Texas Driver License Number

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City

State

Zip Code

Daytime Telephone Number (include area code)

If requesting on behalf of a business, organization, or other entity, please include the following:

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Name of business, organization, entity, etc.

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Your Title or Affiliation with above

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Type of business, organization, etc. (i.e., insurance provider, towing company, private investigation, firm, etc.)

Information Requested On:

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| M | M | / | D |D | / | Y | Y | Y |Y |

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Texas Driver License Number

Date of Birth

Suffix (SR., JR., etc.)

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Last Name

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First Name

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Middle Name/Maiden Name

Individual’s Written Consent For ONE TIME Release to Above Requestor

(Requestor, if you do not meet one of the exceptions listed on the back of this form, please be advised that without the written consent of the driver license/ID card holder, the record you receive will not include personal information.)

I,		, hereby certify that I granted access on this one occasion to my Driver License/ID Card
record, inclusive of the personal information (name, address, driver identification number, etc.) to						.
Signature of License / ID Card Holder or Parent / Legal Guardian				Date

State and Federal Law Requires Requestors to Agree to the Following:

In requesting and using this information, I acknowledge that this disclosure is subject to the federal Driver’s Privacy Protection Act (18 U.S.C. Section 2721 et seq.) and Texas Transportation Code Chapter 730. False statements or representations to obtain personal information pertaining to any individual from the DPS could result in the denial to release any driver record information to myself and the entity for which I made the request. Further, I understand that if I receive personal information as a result of this request, it may only be used for the stated purpose and I may only resell or redisclose the information pursuant to Texas Transportation Code §730.013. Violations of that section may result in a criminal charge with the possibility of a $25,000 fine.

I certify that I have read and agree with the above conditions and that the information provided by me in this request is true and correct. If I am request- ing this driver record on behalf of an entity, I also certify that I am authorized by that entity to make this request on their behalf. I also acknowledge that failure to abide by the provisions of this agreement and any state and federal privacy law can subject me to both criminal and civil penalties.

Signature of Requestor

Date

If you are not requesting a copy of your own record or do not have the written consent of

DL/ID holder, you must provide the information requested on the reverse.

The Texas Department of Public Safety may disclose personal information to a requestor without written consent of the DL/ID holder, on proof of their identity and a certification by the requestor that the use of the personal information is authorized under state and federal law and that the information will be used only for the purpose stated and in complete compliance with state and federal law.

You must meet one or more of the following exceptions if you do not have written consent of the DL/ID holder to be entitled to receive personal information on the above named individual. Please initial each category that applies to the requested driver record.

1.For use in connection with any matter of (a) motor vehicle or motor vehicle operator safety; (b) motor vehicle theft; (c) motor vehicle emissions; (d) motor vehicle product alterations, recalls, or advisories; (e) performance monitoring of motor vehi- cles or motor vehicle dealers by a motor vehicle manufacturer; or (f) removal of nonowner records from the original owner records of a motor vehicle manufacturer to carry out the purposes of the Automobile Information Disclosure Act, the Anti Car Theft Act of 1992, the Clean Air Act, and any other statute or regulation enacted or adopted under or in relation to a law included in the above.

2.For use by a government agency in carrying out its functions or a private entity acting on behalf of a government agency in carrying out its functions.

3.For use in connection with a matter of (a) motor vehicle or motor vehicle operator safety; (b) motor vehicle theft; (c) motor vehicle product alterations, recalls, or advisories; (d) performance monitoring of motor vehicles, motor vehicle parts, or motor vehicle dealers; (e) motor vehicle market research activities, including survey research; or (f) removal of nonowner records from the original owner records of motor vehicle manufacturers.

4.For use in the normal course of business by a legitimate business or an authorized agent of the business, but only to veri- fy the accuracy of personal information submitted by the individual to the business or the authorized agent of the business and to obtain correct information if the submitted information is incorrect to prevent fraud by pursuing a legal remedy against, or recovering on a debt or security interest against the individual.

5.For use in conjunction with a civil, criminal, administrative, or arbitral proceeding in any court or government agency or before any self regulatory body, including service of process, investigation in anticipation of litigation, execution or enforce- ment of a judgement or order, or under an order of any court.

6.For use in research or in producing statistical reports, but only if the personal information is not published, redisclosed, or used to contact any individual.

7.For use by an insurer or insurance support organization, or by a self insured entity, or an authorized agent of the entity, in connection with claims investigation activities, antifraud activities, rating or underwriting.

8.For use in providing notice to an owner of a towed or impounded vehicle.

9.For use by a licensed private investigator agency or licensed security service for a purpose permitted as stated on this page.

10.For use by an employer or an authorized agent or insurer of the employer to obtain or verify information relating to a hold- er of a commercial driver license that is required under 49 U.S.C. Chapter 313.

11.For use in connection with the operating of a private toll transportation facility.

12.For use by a consumer-reporting agency as defined by the Fair Credit Reporting Act (15 U.S.C. §1681 et seq.) for a pur- pose permitted under the Act.

13.For any other purpose specifically authorized by law that relates to the operation of a motor vehicle or to public safety. Please state specific statutory authority

14.For use in the preventing, detecting, or protecting against identity theft or other acts of fraud. The Department prior to release of personal information may require additional information.