4. Appendix B - PA Dept of Transportation Driving History Request.pdf

NAME/coMpANy NAME/coMpANy

ADDRESS ADDRESS (P.O. Box not acceptable), need to provide physical location of business/residence cITy STATE ZIp coDE cITy STATE ZIp coDE

DAyTIME TELEpHoNE NuMbER (required) DAyTIME TELEpHoNE NuMbER (required)

RELATIoNSHIp To DRIvER (required) ________________________________________________ RELATIoNSHIp To DRIvER (required) ________________________________________

Intended use of the Information Requested: CHECK ONLY ONE

❏ B = Driver Release (Driver must complete Section E.)

❏ C = Credit Business (Legitimate Business need in connection with a business transaction initiated by the driver.)

❏ C = Credit Potential Investor, Server or Current Insurer (In connection with an assessment of the credit/payment risks associated with an existing credit obligation.)

❏ E = Employment (To support the hiring or the continuation of employment.

Driver must complete Section E.)

❏ R = Insurance Company requesting record of person it intends to insure, now insures, or has rejected for insurance.

❏ K = Court Order must be attached. (A subpoena issued in compliance with Pa. R.C.P. 4009.21 will be accepted in lieu of a court order).

❏ L = Attorney representing driver identified in Section c (Driver must complete Section E.)

cHEcK (✔) oNE oNLy: ❑ FuLL HISToRy: $5.00 FEE ❑ bASIc INFoRMATIoN: $5.00 FEE (Driver history is not included) ❑ cERTIFIED DRIvER REcoRD: $10.00 FEE ❑ 3 yEAR DRIvER REcoRD: $5.00 FEE ❑ copy oF DocuMENT FRoM FILE (MIcRoFILM): $5.00 FEE ❑ 10 yEAR DRIvER REcoRD: $5.00 FEE (Employment Purposes Only) ❑ cERTIFIED copy oF DocuMENT FRoM FILE: $10.00 FEE

You may obtain a copy of your own 3 year, 10 year and/or Full History Driving Record on PennDOT'S website at www.dmv.state.pa.us REQUESTER INFORMATION B END USER OF INFORMATION BEINg REQUESTED

X

A

NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD

AFFIDAVIT OF INTENDED USED

MoNTH DAy yEAR

DRIVER INFORMATION

NAME: LAST FIRST INITIAL

ADDRESS

cITy

STATE ZIp coDE pHoNE NuMbER

DRIvER NuMbERDATE oF bIRTH

C

MESSENgER NO.

signature

SIGNATuRE oF REQuESTER pRINTED NAME oF REQuESTER

E DRIVER RELEASE

I _______________________________________ hereby request the Department of Transportation to furnish a copy of my pA Driver's Record to ____________________________________________

NAME oF DRIvER

NAME oF pERSoN/coMpANy

SIGNATuRE oF DRIvER DATE X

TypE oF DocuMENT DATE oF vIoLATIoN

(see list of available documents below)

Documents Available:

F MICROFILM

X

SubScRIbED AND SWoRN

To bEFoRE ME: MoNTH DAy yEAR

N O

TA

R

IZ

AT

IO

N

SIGNATuRE oF pERSoN ADMINISTERING oATH

S E A L

X

SIgN IN PRESENCE OF NOTARY

REQUEST FOR DRIVER INFORMATION

The most current version of this form can be found at www.dmv.state.pa.us

PLEASE TYPE OR PRINT IN BLUE OR BLACK INK

DO NOT SEND CASH • See reverSe for inStruCtionS

DL-503 (7-11)

DEPARTMENT OF TRANSPORTATION

Bureau of Driver Licensing P.O. Box 68695 Harrisburg, PA 17106-8695

I hereby certify that _______________________________________________

made herein are true and correct, and that any statement made on or

than two years, or both.

Title ___________________________________________________________

INSTRUCTIONS

B, E or L is checked in Section D. If the Requester is obtaining the information on behalf of someone else, Section B must also be completed.

For overnight and other special mail:

buREAu oF DRIvER LIcENSING buREAu oF DRIvER LIcENSING DRIvER REcoRD SERvIcES DRIvER REcoRD SERvIcES

DESCRIPTION OF INFORMATION AVAILABLE

bASIc INFoRMATIoN ......... Includes name, address, driver number, date of birth and class of license.

3 yEAR REcoRD* .............. Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the past 3 years from the date request is processed. You can obtain a copy of your own record on PennDOT's website at www.dmv.state.pa.us

copy of your own record on PennDOT's website at www.dmv.state.pa.us

FULL HISTORY ������������������� Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the complete history of the driver on file in Pennsylvania�

MIcRoFILM DocuMENT ........................Copies of documents retained by the Department are available for purchase from the microfilm file. You must be specific as to the type of document and the date of the violation/action.

cERTIFIED copy oF DocuMENT ..................Copies of documents from the microfilm file that have been certified by the Department.

IMPORTANT INFORMATION CONCERNINg THE USE OF DRIVER INFORMATION

of pennDoT.

terminated.

($5.00 fee)

DL-503 (7-11)

($5.00 fee)

($5.00 fee)

($5.00 fee)

($10.00 fee)

($5.00 fee)

($10.00 fee)