Dld60 Form – Fill Out and Use This PDF

REQUEST FOR MVR

This form shall be used by persons making requests for a copy of their own driving record (MVR -Motor Vehicle Record) under Utah Code Ann. § 53-3-104 or a copy of their own commercial motor vehicle driver record (CDL - MVR) under Utah Code Ann. § 53-3-420. The form shall only be completed by the subject of

the record.

SUBJECT OF THE RECORD

Please type or print all information.

Subject of the record _______________________________ Date of Birth ___/___/______ License #________________

Daytime Telephone ________________________________

Date of Request __________________________

Mailing Address _________________________________________________________________________________________

Street

City/State

ZIP

Certification Statement: I certify under penalty of law that I am entitled to personal information from the requested driver

record. I am aware that there are criminal and civil penalties for knowingly obtaining, disclosing, or using the personal information for a purpose not permitted under DPPA (18 U.S.C. §§ 2721-2724) and under GRAMA (U.C.A .§ 63G-2-202).

_______________________________________

(Signature of person requesting driving record)

□ Fee of $6.00 enclosed.

TYPE OF MOTOR VEHICLE RECORD (MVR) REQUESTED

□MVR Regular Motor Vehicle Driver Record contains all records of conviction for moving violations and suspensions

within the past three (3) years AND all alcohol/drug-related violations, suspensions, and revocations within the past ten (10) years.

□CDL-MVR COMMERICAL Motor Vehicle Driver Record contains ALL records of conviction for moving violations, including

pleas in abeyance, suspensions, revocations, disqualifications, licenses, and out of state accidents. (Driver must hold a current CDL license to obtain a CDL-MVR)

DLD USE ONLY

Date received

DLD employee

DLD60

Rev. 3-12