Blank Texas Dr 1 PDF Template

MAILTO:DriverRecordsBureau,TexasDepartmentofPublicSafety,Box149246,Austin,TX78714-9246

Type of business, organization, etc. (i.e., insurance provider, towing company, private investigation, firm, etc.)

InformationRequestedOn:

Middle Name/Maiden Name

Individual’sWrittenConsentFor ONETIME ReleasetoAboveRequestor

(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, the record you receive will not include personal information.)

StateandFederalLawRequiresRequestorstoAgreetotheFollowing:

In requesting and using this information, I acknowledge that this disclosure is subject to the federal Driver’s Privacy ProtectionAct (18 U.S.C. Section 2721etseq.)andTexasTransportationCodeChapter730. Falsestatementsorrepresentationstoobtainpersonalinformationpertainingtoanyindivid- ualfromtheDPScouldresultinthedenialtoreleaseanydriverrecordinformationtomyselfandtheentityforwhichImadetherequest. Further,Iunder- standthatifIreceivepersonalinformationasaresultofthisrequest,itmayonlybeusedforthestatedpurposeandImayonlyresellorredisclosethe information pursuant toTexasTransportation Code §730.013. Violations of that section may result in a criminal charge with the possibility of a $25,000 fine.

IcertifythatIhavereadandagreewiththeaboveconditionsandthattheinformationprovidedbymeinthisrequestistrueandcorrect. IfIamrequest- ingthisdriverrecordonbehalfofanentity,IalsocertifythatIamauthorizedbythatentitytomakethisrequestontheirbehalf. Ialsoacknowledgethat 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.

The Texas Department of Public Safety may disclose personal information toarequestorwithoutwrittenconsentoftheDL/IDholder,onproof oftheiridentityandacertificationbytherequestorthattheuseofthepersonalinformationisauthorizedunderstateandfederallawandthat 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 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.Foruseinconnectionwithanymatterof(a)motorvehicleormotorvehicleoperatorsafety;(b)motorvehicletheft;(c)motor vehicle emissions; (d) motor vehicle product alterations, recalls, or advisories; (e) performance monitoring of motor vehi- clesormotorvehicledealersbyamotorvehiclemanufacturer;or(f)removalof nonownerrecordsfromtheoriginalowner records of a motor vehicle manufacturer to carry out the purposes of theAutomobile Information DisclosureAct, theAnti Car TheftAct of 1992, the CleanAirAct, and any other statute or regulation enacted or adopted under or in relation to a law included in the above.

2.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.

3.Foruseinconnectionwithamatterof(a)motorvehicleormotorvehicle operatorsafety;(b)motorvehicletheft;(c)motor vehicle product alterations, recalls, or advisories; (d) performance monitoring of motor vehicles, motor vehicle parts, or motor vehicle dealers; (e) motor vehicle market research activities, including survey research; or (f) removal of nonowner records from the original owner records of motor vehicle manufacturers.

4.Foruseinthenormalcourseofbusinessbyalegitimatebusinessoranauthorizedagentofthebusiness,butonlytoveri- fytheaccuracyofpersonalinformationsubmittedbytheindividualtothebusinessortheauthorizedagentofthebusiness and to obtain correct information if the submitted information is incorrect to prevent fraud by pursuing a legal remedy against, or recovering on a debt or security interest against the individual.

5.For use in conjunction with a civil, criminal, administrative, or arbitral proceeding in any court or government agency or beforeanyselfregulatorybody,includingserviceofprocess,investigationinanticipationoflitigation,executionorenforce- ment of a judgement or order, or under an order of any court.

6.For use in research or in producing statistical reports, but only if the personal information is not published, redisclosed, or used to contact any individual.

7.For use by an insurer or insurance support organization, or by a self insured entity, or an authorized agent of the entity, in connection with claims investigation activities, antifraud activities, rating or underwriting.

8.For use in providing notice to an owner of a towed or impounded vehicle.

9.For use by a licensed private investigator agency or licensed security service for a purpose permitted as stated on this page.

10.Forusebyanemployeroranauthorizedagentorinsureroftheemployertoobtainorverifyinformationrelatingtoahold- er of a commercial driver license that is required under 49 U.S.C. Chapter 313.

11.For use in connection with the operating of a private toll transportation facility.

12.For use by a consumer-reporting agency as defined by the Fair Credit ReportingAct (15 U.S.C. §1681 et seq.) for a pur- pose permitted under theAct.

13.For any other purpose specifically authorized by law that relates to the operation of a motor vehicle or to public safety. Please state specific statutory authority

14.For use in the preventing, detecting, or protecting against identity theft or other acts of fraud. The Department prior to release of personal information may require additional information.