Certified Driver Records Request Form

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1 1 3 5 M S t r e e t S u i t e 2 2 0 L i n c o l n , N E 6 8 5 0 8 | Offic e : 4 0 2 . 4 7 1 . 7 8 1 0 | F a x : 4 0 2 . 4 7 1 . 7 8 1 7
Certified Driver Records Request Form
*County and City Attorneys Only*
1. Please select one:
County Attorney
City Attorney
2. Bar Number:
3. Please add the County's and City's you will be requesting records for:
NOTE: This if for billing purposes.
Counties
Cities
1
2
3
4
5
6
7
8
9
10
4. Fax the form to Nebraska.gov
Subscriber Signature
Email Address
Printed Subscriber Name
Nebraska.gov Account Number
Phone Number/Fax Number
Date
www . n e b r a s k a - i n t e r a c v e . c o m

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