Fillable Form Dpsmv 2106 - Odr Request Form printable pdf download

Form Dpsmv 2106 - Odr Request Form

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LOUISIANA DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS

OFFICE OF MOTOR VEHICLES

P.O. BOX 64886

BATON ROUGE, LA 70896-4886

ODR REQUEST FORM

The disclosure of any personal information collected by the Office of Motor Vehicles is prohibited in

accordance with US Code, Title 18, §2721 through §2725 and §350 of Public Law 106-69, which amended

the Federal Driver Privacy Protection Act OLA File No. 1999-1126 unless:

(Please check which is applicable)

You are the licensee OR

You certify that the intended use of the requested information is only for permitted uses by the

Federal Driver Privacy Protection Act (i.e. government agencies, employers, insurance companies,

law enforcement) OR

You have a written authorization/waiver from the licensee for release of his/her information; licensee

must complete authorization/waiver form below:

AUTHORIZATION/WAIVER TO RELEASE SENSITIVE PERSONAL INFORMATION

I, _____________________________________, do hereby request the Louisiana Office of Motor Vehicles

to release the requestor the information requested.

___________________________________ _______________________________ _________________

Signature

Driver’s License Number

Date

I request that the Louisiana Office of Motor Vehicles furnish me with information contained in the driver’s

license record for the person shown:

Louisiana Driver’s License Number ________________________________

Name of Licensee

________________________________

Date of Birth

________________________________

I hereby certify that the statements contained herein are true and correct to the best of my knowledge,

and that if I am requesting an Official Driving Record on another party, I have permission to do so as

outlined above, OR that the intended use of this information is only for permitted uses as indicated

above.

Print Name of Requestor ___________________________________________________________________

Address _________________________________ City ____________________ State _______ Zip _______

Driver’s License Number _____________________________________ State of Issuance _______________

Signature of Requestor ____________________________________________________________________

DPSMV 2106 (R 8/00)

Form Dpsmv 2106 - Odr Request Form

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