Do 21 Form – Fill Out and Use This PDF

Driver History Abstract

Application Request

New Jersey Motor Vehicle Commission

Business & Government Services

225 East State Street

P.O. Box 142

Trenton, NJ 08666-0142 609-292-6100

A separate form must be completed for each record requested. You may photocopy this form for your convenience; however, each request must bear an original signature of the applicant. No other form of request will be accepted. For applications other than official Government use, the proper fee(s) must accompany each request in the form of a check or money order payable to: “New Jersey Motor Vehicle Commission.” DO NOT SEND CASH. Please note that the turnaround time is approximately 3-4 weeks.

*If you have any questions or need to obtain the status of a request sent by mail, please call 609-292-6100.

ALL APPLICANTS MUST COMPLETE SECTIONS A, B, C, AND E OF THIS FORM. COMPLETE SECTION D, IF APPLICABLE.

(Please print clearly)

SECTION A – Applicant's Information

Applicant’s Name:

Applicant Driver License Number or Government Issued ID Number (Please include a photocopy of your ID):

For Government or Law Enforcement Applicants: Please include a copy of your current Government issued Identification Card. Otherwise,

include a photocopy of your Driver License or a photocopy of a Passport, Birth Certificate, or any valid state or federally issued ID.

SECTION B – Information Requested

NJ Driver License Number (If you do not have the Driver’s License number, you MUST supply name, DOB, gender, and address):

** IF YOU REQUIRE THE ISSUE DATE OF YOUR LICENSE, YOU MUST SUBMIT THE DO-11 FORM.

Driver History Abstract

Application Request

SECTION D – Purpose for the Request (required ONLY when requesting another’s record)

PLEASE READ THE BELOW SECTION OF THE NEW JERSEY DRIVER PRIVACY PROTECTION ACT, INITIAL NEXT TO THE PERMITTED USE(S) THAT APPLY TO YOUR SPECIFIC USE OF THE MVC RECORDS. THEN PROVIDE A WRITTEN EXPLANATION OF THE REASON FOR YOUR REQUEST AND INTENDED USE OF THE INFORMATION.

2. For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls or advisories; performance monitoring of motor vehicles; motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and the removal of non-owner records from the original owner records of motor vehicle manufacturers.

Please include the documentation supporting your request if the information is to be used for motor vehicle emissions, recalls, or advisories, etc.

3. For use in the normal course of business by a legitimate business or its agents, employees or contractors, but only;

a. To verify the accuracy of personal information submitted by the individual to the business or agents, employees or contractors; and

b.If such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the purposes of preventing fraud by pursuing legal remedies against or recovering on a debt or security interest against the individual.

Please include a copy of the individual release consent form.

4. For use in connection with any civil, criminal, administrative or arbitral proceeding in any Federal, State, or Local court or agency or before any self- regulating body, including service of process, investigation in anticipation of litigation, and the execution or enforcement of judgements and orders, or pursuant to an order of a Federal, State, or Local court.

Please include the Docket number and a letter from the client confirming that you have been retained. Please provide an explanation if no Docket number has been assigned. If no Docket number is available, please submit the case file number on Attorney letterhead and include a copy of the accident report.

5. For use in educational initiatives, research activities, and for use in producing statistical reports, so long as the personal information is not published, redisclosed, or used to contact individuals and, in the case of educational initiatives, only organ procurement organizations as aggregated, non-identifying information.

Please include a description of the initiative or research on official letterhead.

6. For use by an insurer or insurance support organization, or by a self-insured entity, or its agents, employees, or contactors, in connection with claims investigation activities, antifraud activities, rating or underwriting.

9.For use in connection with the operation of private toll transportation facilities.

If your request does not fall under one of the above reasons:

10.For use by any applicant, if the applicant demonstrates it has obtained the notarized written consent of the individual to whom the information

pertains.

*Please note: If you selected number 10, a “Notarized Authorization to Release Personal Motor Vehicle Information” (Form BGS/DO- 21A) must be submitted and will not be accepted unless it is acknowledged by a Notary Public or Attorney at Law.

Driver History Abstract

Application Request

Explanation of reason

Please explain in detail your reason for requesting this information and how you plan to use it. If involving a lawsuit, please state the type of lawsuit and your relationship to the case.

Driver History Abstract

Application Request

SECTION E – Terms and Conditions

The disclosure and use of personal information * contained in the record you have requested is governed by the “New Jersey Drivers’ Privacy Act” (NJDPPA), N.J.S.A. 39:2-3.3 et seq. The NJDPPA provides that a person who knowingly obtains or discloses information from a motor vehicle record for any use not permitted by the Act is guilty of a crime of the fourth degree and can be held liable, in a civil action in the Superior Court, to the individual to whom the information pertains, including an award of actual damages, punitive damages, and reasonable attorney’s fees and litigation costs.

*“Personal Information” means information that identifies an individual, including an individual’s photograph; social security number; driver identification number; name; address other than the five-digit zip code; telephone number; and medical or disability information, but does not include information on vehicular accidents, driving violations, and driver’s status.

I hereby certify that the foregoing statements and submitted supporting documents are true. I understand that if any of the statements or submitted supporting documents are willfully false, I am subject to punishment. I have read N.J.S.A. 39:2-3.3, et seq. (NJDPPA) and I have initialed all the permitted purposes that apply to my request for online access. I will only use any personal information contained in records I have requested as permitted by the NJDPPA.

I agree to hold the New Jersey motor Vehicle Commission (NJMVC) harmless in the event of any errors or omissions in the record and document(s) furnished under this application.

If I am requesting another’s record, I certify that:

1.Use of the information provided by the NJMVC pursuant to this Application will only be for the purposes explicitly set forth in this Application;

2.The information provided by the NJMVC pursuant to this Application will not be used for the purpose of commercial solicitation or marketing, political canvassing or campaigning or any similar purpose or objective, and I shall not provide such information to any person or entity that seeks to use such information for any of these purposes;

3.If the information requested is to be used “in anticipation of litigation,” pursuant to N.J.S.A. 39:2-3.4(c)4, personal information will only be used where litigation is imminent or foreseeable, or where the party on whose behalf the information is obtained has made the conscious decision to prepare a claim or defend against a probable claim;

4.In the event of a breach of any of the security obligations or other event requiring notification under applicable law, I shall comply with all applicable State and Federal laws that require notification of individuals in the event of unauthorized release of Person Information, or other event requiring notification, and assume responsibility for informing the NJMVC within twenty-four (24) hours and all such appropriate individuals, including the customer whose information is the subject of the release, in accordance with applicable law and to indemnify, hold harmless and defend the State of New Jersey from, and against any claims, damages, or other harm related to such breach or event. All communications must be coordinated with the State of New Jersey by contacting the NJMVC at 609-341-5777.