Columbus Municipal Court Driving Offences Options Page 3

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APPUCATON FOR COPY OF DRVER RECORD

Mail to: Driver Records Bureau, Texas Department of Public Safety, Box 149246, Austin, Texas 78714-9246

MAKE CASHIER’S CHECK or MONEY ORDER PAYABLE TO: TEXAS DEPARTMENT OF PUBLIC

SAFETY

Any questions regarding the information on this form should be directed to Customer Service at 512/424-2600. Allow 2-3 weeks for delivery.

CHECK TYPE OF RECORD DESIRED

FEE

1. Name

DOB

License Status

Latest Address.

4.00

2. Name

DOB

License Status

List of Accidents/Moving Violations in Record within Immediate Past 3 Year Period,

6.00

2A. CERTIFIED version of #2. This Record Is Not Acceptable for DDC Course.

10.00

3. Name

DOB

License Status

List of ALL Accidents and Violations in Record. Furnished to Licensee ONLY.

7.00

3A. CERTIFIED version of #3. Furnished to Licensee ONLY and is Acceptable for DDC Course

$ 10.00

Other: (Original Application, DWLS, etc.)___________________________________________________ (If Required)

MAIL DRIVER

RECORD TO:

(PLEASE TYPE OR PRINT)

Address

P. 0

Box 705

City, State, Zip Code

CoIumbus TX 78934

Telephone #

9797323981

If requesting on behalf of a business, organization, or other entity, please include the following:

Name of business, organization, entity, etc.

COLUMBUS MUNICIPAL COURT

Your Title or Affiliation with above

MUNhCIPAL COURT CLERK

Type of business, organization, etc.

MUNICIPAL COURT

(i.e. Insurance provider, towing company, private investigation firm, etc.)

INFORMATION REQUESTED ON:

Texas Driver License #

Date of Birth (Month/Day/Year)

Last Name

First Name

Middle/Maiden

INDMDUAL’S WRITTEN CONSENT FOR ONE TIME RELEASE TO ABOVE REQUESTOR

(Requestor, if you do not

meet one of the exceptions listed on the back of this form, please be advised that without the

written consent of the driver

licence/ID card holder, the record you receive will not include personal information.)

hereby certify that I grant access on this one occasion to my Driver License/ID Card record, inclusive of the

personal information (name, address, driver identification number, etc.),

to Columbus Municipal Court.

Signature of License/ID Card Holder or Parent/Legal Guardian

Date

State and federal law requires requestors to agree to the following:

In requesting and using this information, I acknowledge that this disclosure is subject to the federal Driver’s Privacy Protection Act

(18 U.S.C. Sect. 2721

et seq.) and Texas Transportation Code Chapter 730. False statements or representations to obtain personal information pertaining to any individual

from the DPS could result in the denial to release any driver record information to myself and the entity for which I made the request. Further,

understand

that if I receive personal information as a result of this request, it

may only be used for the stated purpose an dl may only resell or redisclose the informa

tion pursuant to Texas Transportation Code §730.013. Violations of that section may result in a criminal charge with the possibility of a $25,000 fine.

certify that I have read and agree with the above conditions and that the information provided by me in this request is true and correct. If lam requesting

this driver record on behalf of an entity, I also certify that

am authorized by that entity to make this request on their behalf. I also acknowledge that failure

to abide by the provisions of this agreement and any state and federal privacy law can subject me to both criminal and civil penalties.

Signature of Requestor

Date

you are not requesting a copy of your own record or

not have

the

written

consent of

DL/ID holder,

you must provide