Pennsylvania Release Form - Maf Background Screening Page 2
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1
2DL-503 (8-08)
request for driver information
The most current version of this form can be found at
PLease tYPe or Print in BLue or BLaCK inK
Bureau of Driver Licensing
do not send CASH • See reverSe for inStruCtionS
P.O. Box 68695
D E PA R T M E N T O F T R A N S P O R TAT I O N
Harrisburg, PA 17106-8695
cHEcK (✔) oNE oNLy:
❑
❑
bASIc INFoRMATIoN: $5.00 FEE (Driver history is not included)
cERTIFIED DRIvER REcoRD: $10.00 FEE
❑
❑
3 yEAR DRIvER REcoRD: $5.00 FEE
copy oF DocuMENT FRoM FILE (MIcRoFILM): $5.00 FEE
❑
❑
10 yEAR DRIvER REcoRD: $5.00 FEE (Employment Purposes Only)
cERTIFIED copy oF DocuMENT FRoM FILE: $10.00 FEE
You may obtain a copy of your own 3 Year and/or 10 Year Driving Record on PennDOT'S Web site at
A
REQUESTER INFORMATION
B
END USER OF INFORMATION BEINg REQUESTED
NAME/coMpANy
NAME/coMpANy
Softech International Inc
ADDRESS
ADDRESS (P.O. Box not acceptable), need to provide physical location of business/residence
P.O. Box number may be used in addition to the actual address, but cannot be used as the
only address.
13501 SW 128th Street Suite 111
cITy
STATE
ZIp coDE
cITy
STATE
ZIp coDE
Miami
33186
FL
______________
(305) 253-9696
(
)
(
)
DAyTIME TELEpHoNE NuMbER (required)
DAyTIME TELEpHoNE NuMbER (required)
______________________
Application Processing
Potential Employer
________________________________________
RELATIoNSHIp To DRIvER (required) ________________________________________________
RELATIoNSHIp To DRIvER (required)
D
AFFIDAVIT OF INTENDED USE
Intended use of the Information Requested: CHECK ONLY ONE
X
signature
❏
B = Driver Release (Driver must complete Section E.)
NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD
❏
C = Credit (In connection with a credit transaction involving the driver.)
C
DRIVER INFORMATION
❏
E = Employment (To support the hiring or the continuation of employment.
Driver must complete Section E.)
NAME:
LAST
FIRST
INITIAL
❏
R = Insurance Company requesting record of person it intends to insure,
now insures, or has rejected for insurance.
ADDRESS
❏
K = Court Order must be attached. (A subpoena issued in compliance with
Pa. R.C.P. 4009.21 will be accepted in lieu of a court order).
cITy
❏
L = Attorney representing driver identified in Section c (Driver must
complete Section E.)
STATE
ZIp coDE
Softech International Inc
pHoNE NuMbER
I hereby certify that _______________________________________________
(
)
pRINTED NAME oF REQuESTER
will use the driver record abstract(s) required pursuant to Section 6114
DATE oF bIRTH
DRIvER NuMbER
of the pennsylvania vehicle code, for the purpose checked above only
MoNTH
DAy
yEAR
and no other reason. This affidavit is filed in compliance with Section
607 of the Fair credit Reporting Act. I/We have read and signed this
form after its completion, and I/We swear or affirm that the statements
E DRIVER RELEASE
made herein are true and correct, and that any statement made on or
pursuant to this form is subject to the penalties of 18 pa c.S. Section
I _______________________________________ hereby request
4903(a)(2) (relating to false swearing), which shall include punishment
of a fine not exceeding $5,000, or to a term of imprisonment of not more
NAME oF DRIvER
the Department of Transportation to furnish a copy of my pA Driver's
than two years, or both.
Softech International Inc
Record to ____________________________________________
NAME oF pERSoN/coMpANy
X
X
_______________________________________________________________
SIGNATuRE oF REQuESTER
SIGNATuRE oF DRIvER
DATE
Coordinator
F MICROFILM
Title ___________________________________________________________
TypE oF DocuMENT
DATE oF vIoLATIoN
SubScRIbED AND SWoRN
To bEFoRE ME:
MoNTH
DAy
yEAR
X
(see list of available documents below)
SIGNATuRE oF pERSoN ADMINISTERING oATH
Documents Available:
• Citations
• Suspension Credit Affidavits
S
• Court Certifications
• Suspension/Revocation Letters
• Applications
• Restoration Letters
E
• License Renewals
• Rescind Letters
SIgN IN PRESENCE OF NOTARY
A
• Judgments
• Department Hearing or Exam Notice
L
MESSENgER NO.
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