Mva Request For Motor Vehicle Administration Records

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Motor Vehicle Administration

DR-057 (01-15)

6601 Ritchie Highway, N.E.

Glen Burnie, Maryland 21062

Certified Record: $12.00

Request for Motor Vehicle Administration Records

Non-Certified Record: $9.00

Please complete all requested information as applicable.

Subject of Record:

Type of Record:

3 year driving record

Vehicle record

*Complete driving record (all information in MVA data base).

Tag No.:

*PBJ driving record

VIN:

*Available to: individual of record or individual’s attorney; police or judicial

Yr./Make/Model:

system; authorized representative of any federal, state or local govern-

ment; or authorized employer of CDL drivers.

Driver Record

Application for driver’s record/identification card.

Title record.

Name:

Certified copy of Maryland title for export of vehicle.

DOB:

Registration record.

LIC #:

Original issue date of license.

Address:

Other:

Requestor Information:

Please complete this section if record is to be mailed.

Please print or type information.

Name:

LIC #:

Address (Home):

Full Name:

Telephone (Home):

Address (Work):

Street Address:

City:

Telephone (Work):

Identification (MVA Use Only):

State:

Zip Code:

Type of Identification Accepted:

LIC #:

Other Number:

Verified By:

Status:

Business Name:

Attorney (Please sign “Attorney Certification” if requesting complete

driving record of your client)

Law Enforcement/Government Agency

“I certify that I am the attorney for the individual whose complete driving record

Name:

or PBJ is being requested.”

Insurance Company

Attorney’s Signature:

Name:

Employer:

Researcher:

“I certify that I am an employer or potential employer of the individual for whom

I am requesting/receiving a driving record, and that a valid commercial driver’s

Own record:

license is required of the individual as a condition of employment.”

Other: Please specify:

Employer’s Signature:

Printed Name:

Purpose of Request:

My signature acknowledges, under penalty of criminal prosecution, that I will use information received from the Motor Vehicle Administration (MVA)

solely for the purpose I describe on this application, and further agree that I will not release personal information obtained from MVA records except

as permitted by Title 4 of the General Provisions Article (Maryland Public Information Act).

I understand and acknowledge that by requesting information from Motor Vehicle Administration records I have read and agree to the terms of the

MVA Privacy Protection Agreement on the reverse side of this form. I also acknowledge that I have read the Notice of Appeal Procedure also set forth

on the reverse side.

Signature: _________________________________________ Printed name: ______________________________________ Date: _______________________

❒

MVA Use Only:

Certified

Non-Certified

Cash

Check

Credit Card