Fillable Form 419f - Request For Driving Record printable pdf download

Form 419f - Request For Driving Record

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STATE OF ALASKA

DIVISION OF MOTOR VEHICLES

REQUEST FOR DRIVING RECORD

There is a $10 fee for each type of driving record selected. PLEASE PRINT CLEARLY.

Submit request to DMV Research:

SELECT RECORD TYPE:

1300 W. Benson Blvd., Suite 410

Anchorage, AK 99503

FULL INDIVIDUAL RECORD

Phone: 907-269-3754

Shows current driving record status, and includes all convictions, license actions, and at-fault

Fax: 907-269-5202

accidents on record; includes full medical certification details for commercial (CDL) drivers.

Email: doa.dmv.research@alaska.gov

INSURANCE RECORD

Shows current driving record status, and 3 or 5 year history of convictions, license actions, and at-fault accidents required for vehicle insurance

purposes; excludes any medical certification information on record. (3 or 5 year reporting requirement is based on the type of conviction or action.)

CDL EMPLOYMENT RECORD

Shows current driving record status; full medical certification information; and conviction, license action, and at-fault accident information as

required by DOT regulations for commercial (CDL) drivers. CDL drivers must select this type of record when used for CDL employment purposes.

REQUESTOR INFORMATION

Requestor Name

Phone Number

Alaska Driver License Number

Date of Birth

Social Security Number

AND

RELEASE TO ANOTHER PERSON OR COMPANY (OPTIONAL)

By initialing this box I authorize the DMV to release my driving record to the person or company listed below:

Printed Name

Contact Phone Number

I WANT MY RECORD TO BE SENT VIA:

Fax

Mail (Select only one)

Email Address

Fax Number

Mailing Address

Signature of Requestor

Date (Valid for 90 days)

PAYMENT INFORMATION

Make check or money order payable to DMV or State of Alaska. DO NOT MAIL CASH.

MasterCard or Visa #

Expiration Date

Name as shown on card

Security Code (3 digit code on back of card)

I understand that my credit card will be charged $10 for each driving record.

Signature of credit card holder

Date

(Valid for 90 days)

DMV USE ONLY

BATCH

AMVC ID / OFFICE

I have verified ID for in-person request

$10

Expiration Date:

FEE:

Form 419F Rev. 1/2016

Form 419f - Request For Driving Record

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