DR-1 (Rev. 10/16) APPLICATION FOR COPY OF DRIVER RECORD | | | | | | | Check Type of Record Desired DO NOT MAIL CASH. Mail check or money order payable to: Texas Department of Public Safety MAIL TO: Texas Department of Public Safety, Box 149008, Austin, TX 78714-9008 TEXAS DPS *012004* FEE Any questions regarding the information on this form should be directed to the Contact Center at 512-424-2600. Allow 2-3 weeks for delivery. | 2A. CERTIFIED version of #2. This Record is Not acceptable for a Defensive Driving Course (DDC). | 4. Abstract Record ­ Certified abstract of completed driver record. | Other: (Original Application, DWLI, etc.) | | | | | | | | | | | | | | | | | | 3A. CERTIFIED version of #3. Furnished to Licensee Only and is Acceptable for DDC. | | | | | | | | | | | | | | 2. Name ­ DOB ­ License Status ­ 3 Year Record only lists Crashes/Moving Violations. | 1. Name ­ DOB ­ License Status ­ Latest Address. | 3. Name ­ DOB ­ License Status ­ Record of ALL Crashes/Violations. Furnished to Licensee Only. | | | | | | | | | | $| $ 10.00 $ 20.00 | $ 10.00 $ 6.00 $ 4.00 $ 7.00 |.00 | | | | | | Mail Driver Record To: (Please Print or Type) Requestor's Last Name Street Address City (If Required) | | | | | | | | | | | | | | | | | | | | | | | | | | | | If requesting on behalf of a business, organization, or other entity, please include the following: Name of business, organization, entity, etc. Your Title or Affiliation with above | | | | | | | | | State | | | | | | | | | Requestor's First Name Zip Code | | | | | | | | | | | | Texas Driver License Number | Daytime Telephone Number (include area code) | | | | |-| | | | | | | | | |-| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Information Requested On: Texas Driver License Number Type of business, organization, etc. (i.e., insurance provider, towing company, private investigation, firm, etc.) Last Name | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | M | M | / | D |D | / | Y | Y | Y | Y | Date of Birth | | | | | | | | | | | | | | | || || || | | | | | | | | | | | | | | | | | | | | | || || || | | | | Suffix (SR., JR., etc.) | | | | | | | | | | | | | | | | | | | | | | | | | | First Name record, inclusive of the personal information (name, address, driver identification number, etc.) to Signature of License / ID Card Holder or Parent / Legal Guardian I, (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.) , hereby certify that I granted access on this one occasion to my Driver License/ID Card . Date Individual's Written Consent For ONE TIME Release to Above Requestor Middle Name/Maiden Name In requesting and using this information, I acknowledge that this disclosure is subject to the federal Driver's Privacy Protection Act (18 U.S.C. Section 2721 et seq.) and Texas Transportation Code Chapter 730. False statements or representations to obtain personal information pertaining to any individual from the DPS could result in the denial to release any driver record information to myself and the entity for which I made the request. Further, I understand that if I receive personal information as a result of this request, it may only be used for the stated purpose and I may only resell or redisclose the information pursuant to Texas Transportation Code §730.013. Violations of that section may result in a criminal charge with the possibility of a $25,000 fine. State and Federal Law Requires Requestors to Agree to the Following: I certify that I have read and agree with the above conditions and that the information provided by me in this request is true and correct. If I am requesting this driver record on behalf of an entity, I also certify that I am authorized by that entity to make this request on their behalf. I also acknowledge that 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. Signature of Requestor If you are not requesting a copy of your own record or do not have the written consent of DL/ID holder, you must provide the information requested on the reverse. American LegalNet, Inc. www.FormsWorkFlow.com Date Texas Department of Public Safety The Texas Department of Public Safety may disclose personal information to a requestor without written consent of the DL/ID holder, on proof of their identity and a certification by the requestor that the use of the personal information is authorized under state and federal law and that 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. For use in connection with any matter of (a) motor vehicle or motor vehicle operator safety; (b) motor vehicle theft; (c) motor vehicle emissions; (d) motor vehicle product alterations, recalls, or advisories; (e) performance monitoring of motor vehicles or motor vehicle dealers by a motor vehicle manufacturer; or (f) removal of nonowner records from the original owner records of a motor vehicle manufacturer to carry out the purposes of the Automobile Information Disclosure Act, the Anti Car Theft Act of 1992, the Clean Air Act, and any other statute or regulation enacted or adopted under or in relation to a law included in the above. 2. (Valid for Certified Abstract) 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. Important Instructions ­ Read Carefully Save Time ­ Request Your Driver Record Online www.texas.gov 3. For use in connection with a matter of (a) motor vehicle or motor vehicle operator safety; (b) motor vehicle theft; (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 res