
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.
TEXAS DPS
APPLICATION FOR COPY OF DRIVER RECORD
MAIL TO: Driver Records Bureau, Texas Department of Public Safety, Box 149246, Austin, TX 78714-9246
Check Type of Record Desired FEE
Mail Driver Record To: (Please Print or Type)
Information Requested On:
Individual’s Written Consent For
ONE TIME
Release to Above Requestor
State and Federal Law Requires Requestors to Agree to the Following:
Make CHECK or MONEY ORDER Payable To:
TEXAS DEPARTMENT OF PUBLIC SAFETY
Any questions regarding the information on this form should be directed to
Customer Service at 512-424-2600. Allow 2-3 weeks for delivery.
| | 1. Name - DOB - License Status - Latest Address. $ 4.00
| | 2. Name - DOB - License Status - List of Accidents/Moving Violations in Record within Immediate Past 3 Year Period. $ 6.00
| | 2A. CERTIFIED version of #2. This Record is Not Acceptable for DDC Course. $ 10.00
| | 3. Name - DOB - License Status - List of ALL Accidents and Violations in Record. Furnished to Licensee ONLY. $ 7.00
| | 3A. Certified version of #3. Furnished to Licensee ONLY and is Acceptable for DDC Course. $ 10.00
| | Other: (Original Application, DWLS, etc.) | | | | | | | | | | | | | | | | | | | $ | | |.00
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | - | | | | - | | | | |
If requesting on behalf of a business, organization, or other entity, please include the following:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | / | | | / | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
(If Required)
Requestor’s Last Name
Requestor’s First Name
State
Zip Code
Daytime Telephone Number (include area code)
Texas Driver License NumberStreet Address
City
Name of business, organization, entity, etc.
Your Title or Affiliation with above
Type of business, organization, etc. (i.e., insurance provider, towing company, private investigation, firm, etc.)
Texas Driver License Number
Last Name
Middle Name/Maiden Name
Date of Birth
Suffix (SR., JR., etc.)
First Name
M M
D D
Y Y Y Y
(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.)
I,
, hereby certify that I granted access on this one occasion to my Driver License/ID Card
record, inclusive of the personal information (name, address, driver identification number, etc.) to .
Signature of License/ID
Card Holder or
Parent/Legal Guardian
Date
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 individ-
ual 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 under-
stand 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.
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 request-
ing 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
Date
*012004*
DR-1 (Rev. 5/08)