I, _____________________________________, do
hereby authorize the Division of Motor
Vehicles to release my driving record to
End User Company Name
____________________________________
Address 1:
__________________________________________
Address 2:
__________________________________________
City: _________________________State: _______Zip
code: __________
Phone number ___________________
This release shall remain in full force and
effect until I, myself file formal withdrawal.
Driver’s Full Name:
_________________________________
Date of Birth:
_____________________________________
Driver’s License Number:
_________________________________________
________________________________
Signature
