Form Dr 36 – Fill Out and Use This PDF

Mail coMpleted forM and $20 fee to:

texas department of public Safety, po Box 149008, austin, texas 78714-9008

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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, your request will be returned.

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 Driver 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 pertain- ing 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 requesting 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.

important instructions - read carefully

The Texas Department of Public Safety may disclose personal information to a requestor without written consent of the DL/ID card 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 card 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 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.

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

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