Notarized Authorization To Release Personal Motor Vehicle Information
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Notarized Authorization To Release Personal Motor Vehicle Information Form. This is a New Jersey form and can be use in Motor Vehicle Commission Statewide.
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Tags: Notarized Authorization To Release Personal Motor Vehicle Information, DO-21A, New Jersey Statewide, Motor Vehicle Commission
NOTARIZED AUTHORIZATION TO RELEASE
PERSONAL MOTOR VEHICLE INFORMATION
(Please Print)
I, _________________________________, grant permission to __________________________________ to
(Name of granter)
(Name of recipient)
receive my personal driver history record and any other personal motor vehicle information deemed appropriate
for release under the “Drivers’ Privacy Protection Act”.
Date_________________________
________________________________________
(Signature of person granting release)
#_________________________________
(DL number of person granting release)
____________________________________________________
Street Address
____________________________________________________
City
State
Zip
On this ________ day of ______________ 20_______, ____________________________ personally appeared
(Name of granter)
before me and acknowledged that the foregoing authorization was approved and signed by him/her.
______________________________
Notary Public in and for the County of
____________________State ______________
My Commission expires _________________
This form, when properly completed and signed, will be accepted by the New Jersey Motor Vehicle Commission
as satisfactory authorization to release personal motor vehicle information concerning the individual named
above to the second party named above.
THIS FORM WILL NOT BE ACCEPTED UNLESS IT IS ACKNOWLEDGED
BY A NOTARY PUBLIC OR ATTORNEY AT LAW
BGS/DO-21A (R4/08)
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