TRANSIT DRIVER NOTIFICATION SYSTEM
DRIVER’S DISCLOSURE FORM
This form is to be used and kept by your agency in compliance with the Federal Driver’s Privacy Protection Act and
NC General Statute 20-43.1. A copy for each driver must be kept on file for five years.
Effective September 13, 1997, all motor vehicle records are subject to the Federal Driver’s Privacy Act (FDPPA) and General Statute 20-43.1.
The FDPPA and the GS 20-43.1 require that personal information in the Division of Motor Vehicles records be closed to the public. Personal
Information from these records may be released to individuals or organizations that qualify under one of the fourteen (14) exceptions listed on the
back of this form. These exceptions are summarized statements of permissible uses.
Name of Driver:
State of DL:
DL Expire Date:
Date of Birth:
City: _______________________ State: _____________ Zip Code: _____________________________
Work Phone #:
By signing this form, you are granting the company access to your personal information under exception number 13 of the FDPPA and
NAME OF COMPANY/AGENCY:
SIGNATURE OF DRIVER:
My signature on this document acknowledges that I understand that improper release of Information and/or false representation to gain
information form the DMV’s records is prohibited and is subject to civil action.
NAME OF REQUESTER/CONTRACT: ___________________________________________________
REQUESTER’S SIGNATURE: ______________________________DATE: ______________________
My signature on this document acknowledges that I understand that improper release of information and/or false representation to gain
information from the DMV’s records is prohibited and is subject to civil action.
COMPANY/AGENCY APPROVAL AUTHORITY: _________________________________________
SIGNATURE: ____________________________________________ DATE: _____________________
*****INCLUDE COPY OF DRIVERS LICENSE*****