Mvd Form 34 0100 – Fill Out and Use This PDF

P . O. Box 2 0 1 4 3 0 H e le n a , M T 5 9 6 2 0 - 1 4 3 0

 Ph on e ( 4 0 6 ) 4 4 4 - 3 9 3 3  Fa x ( 4 0 6 ) 4 4 4 - 3 8 1 6

Of f ice

1 . Re qu e st e d I n for m a t ion

Use

[ 3 ]

A. Your Dr iving Recor d – Com plet e Sect ions 3, 4, 5, and 6 .

[ 3]

B. Anot her Person’s Driving Recor d – Com plet e all sect ions, including I nt ended Use below .

I n t e n de d Use : To be com plet ed if you checked B above.

[ 1]

For use by a feder al, st at e, or local gover nm ent agency, including a law enforcem ent agency or any individual act ing on behalf of t he agency

in car r ying out it s funct ions.

[ 2]

For use by a business or it s agent s, em ployees, or cont r act ors in t heir nor m al cour se of business t o verify t he accur acy of per sonal

infor m at ion subm it t ed by t he individual t o t he business or it agent s, em ployees, or cont r act ors. I f t he subm it t ed infor m at ion is not cor rect or

no longer cor rect , t o obt ain t he cor rect inform at ion for t he pur poses of prevent ing fraud by pursuing legal r em edies against or r ecovering on

a debt or secur it y int er est against t he individual.

[ 4]

Wit h w rit t en consent of t he individual( s) who is t he subj ect ( s) of t his search - A signed and dat ed Personal I nfor m at ion Express Consent form

m ust be at t ached.

[ 5]

For use as par t of a civil, crim inal, adm inist r at ive, or ar bit rat ive pr oceeding in any court or governm ent agency or before any self - r egulat or y

body, including t he ser vice of process, an invest igat ion in ant icipat ion of lit igat ion, and t he execut ion or enforcem ent of j udgm ent s and

or der s, pursuant t o an or der of any court .

[ 6]

For use by an insur er , insur ance support agency, or self- insured ent it y in connect ion wit h t he invest igat ion of claim s, ant ifr aud act ivit ies,

r at em aking, or underw rit ing.

[ 7]

For use by a licensed privat e invest igat or or secur it y ser vice for any pur pose aut horized under Mont ana law .

[ 8]

For use by an em ployer or it s agent t o verify infor m at ion r elat ed t o a holder of a com m ercial driver license required under feder al or Mont ana

law .

[ 9]

For use in pr oviding not ice t o t he ow ners of t owed, abandoned, or im pounded vehicles.

[ 10]

For use by a par ent of a child under 18 year s of age.

[ 11]

For any ot her use t hat is specifically relat ed t o t he oper at ion of a m ot or vehicle or t o public safet y and is aut horized under Mont ana law .

2 .

Re qu e st or I n for m a t ion

N a m e of Re que st or :

Em ployer / Com pany: ( if applicable)

Mailing Addr ess:

Cit y:

St at e:

Zip:

Resident ial Address:

Cit y:

St at e:

Zip:

Dayt im e Phone # :

Driver License # :

3 .

Se a r ch I n form a t ion : Th is se ct ion m ust be com ple t e .

4 . D r ivin g Re cor ds Fe e s

M a k e ch e ck s pa y a ble t o: M ot or V e hicle D iv ision

Full Nam e:

Driving Recor d = $ 4 per r ecor d

Cert ified Dr iving Recor d = $ 10 per recor d * Cannot Be

Dat e of Bir t h:

Faxed *

Faxing of Recor d =

Addit ional $3 per recor d

Fax # :

Driver License # :

________________________________________

Mailing of Recor d =

Addit ional $3 per m ailing ( unless

self- addr essed, st am ped envelope is in cluded)

Tot a l =

$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5 .

Ce r t ifica t ion ( Signat ur e m ust be not ar ized unless a copy of r equest or ’s dr iv er license or st at e- issued ident ificat ion card is enclosed. )

Signat ur e of request or :

Pr int ed Nam e:

Dat e:

St at e of

Count y of

Signed befor e m e on ( dat e)

Not ar y St am p/ Seal

By ( clear ly pr int nam e of per son signin g for m )

Not ar y signat ur e

3 4 - 0 1 0 0 ( 8 / 15)

Pr int Fu ll Nam e

Driver License # :

Dat e of Birt h:

Residing at :

St r eet

Cit y

St at e

Zip Code

I h er eby aut horize t he Depart m ent of Just ice t o r elease m y:

Driving Record

Vehicle Record

This is m y legal signat ur e

Dat e

Print ed nam e: