Form 419m - Company Release For Multiple Driving Records

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STATE OF ALASKA
DIVISION OF MOTOR VEHICLES
COMPANY RELEASE FOR MULTIPLE DRIVING RECORDS
Company or Business Name (Please Print)
Telephone Number
The undersigned authorizes the DMV to release their driving record to the above business or company:
DATE
ALASKA DRIVER
PRINTED NAME
**
SIGNATURE
CIRCLE RECORD TYPE
(Valid for
LICENSE NUMBER
90 days)
Full
CDL
Insurance
Individual
Employment
Full
CDL
Insurance
Individual
Employment
Full
CDL
Insurance
Individual
Employment
Full
CDL
Insurance
Individual
Employment
Full
CDL
Insurance
Individual
Employment
Full
CDL
Insurance
Individual
Employment
Full
CDL
Insurance
Individual
Employment
** Driving Record Types (What’s the difference?)
Full Individual Record:
Submit requests to DMV Research:
Shows current driving record status, and includes all convictions, license actions, and at-fault
1300 W. Benson Blvd., Suite 410
accidents on record; includes full medical certification details for commercial (CDL) drivers.
Anchorage, AK 99503
Insurance Record:
Phone: 907-269-3754
Shows current driving record status, and 3 or 5 year history of convictions, license actions, and at-
Fax: 907-269-5202
fault accidents required for vehicle insurance purposes; excludes any medical certification
Email: doa.dmv.research@alaska.gov
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.
I want the driving records to be sent via:
Email
Fax
Mail (Select only one)
Mailing Address
Fax Number
City / State / Zip
Email
Make checks payable to DMV, or State of Alaska, OR complete the following to make payment by credit card.
Card Number (Visa or MasterCard)
Exp. Date
Security Code (3 digit code on back of card)
Name as shown on card
I understand that the credit card shown above will be charged $10 for each record type selected.
Authorized Cardholder Signature
Date (Valid for 90 days)
DMV USE ONLY
BATCH
AMVC ID / OFFICE
I have verified ID for in-person request
TOTAL FEES: _______
CA
CC CK
Expiration Date:
Form 419M Rev.1/2016

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