REQUEST FOR DRIVER INFORMATION

DL-503 (7-19)
REQUEST FOR DRIVER INFORMATION
DO NOT SEND CASH • SEE REVERSE FOR INSTRUCTIONS
CHECK (✔) ONE ONLY:

BASIC INFORMATION: $11.00 FEE (Driver history is not included)3 YEAR DRIVER RECORD: $11.00 FEECERTIFIED DRIVER RECORD: $36.00 FEEFULL HISTORY: $11.00 FEECOPY OF DOCUMENT FROM FILE (MICROFILM): $11.00 FEE10 YEAR DRIVER RECORD: $11.00 FEE (Employment Purposes Only)CERTIFIED COPY OF DOCUMENT FROM FILE: $36.00 FEE
You may obtain a copy of your own 3 year or 10 year Driving Record on PennDOT'S website at www.dmv.pa.gov
A REQUESTER INFORMATION
END USER OF INFORMATION BEING REQUESTED
ADDRESS
P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.
ADDRESS (P.O. Box not acceptable), need to provide physical location of business/residence
CITY
STATE ZIP CODE
STATE ZIP CODE
CITY
STATE ZIP CODE
STATE ZIP CODE
DAYTIME TELEPHONE NUMBER (REQUIRED)
DAYTIME TELEPHONE NUMBER (REQUIRED)
DAYTIME TELEPHONE NUMBER (REQUIRED)
DAYTIME TELEPHONE NUMBER (REQUIRED)
RELATIONSHIP TO DRIVER (REQUIRED)
RELATIONSHIP TO DRIVER (REQUIRED)
AFFIDAVIT OF INTENDED USE
SIGNATURE
NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD
DRIVER INFORMATION
C = Credit Business Legitimate Business need in connection with a business transaction initiated by the driver

B = Driver Release Driver must complete Section EIntended Use of the Information Requested:CHECK ONLY ONEC = Credit Potential Investor, Server or Current Insurer In connection with an assessment of the credit/payment risks associated with an existing credit obligation
C = Credit Business Legitimate Business need in connection with a business transaction initiated by the driver

E = Employment To support the hiring or the continuation of employment. Driver must complete Section ER = Insurance Company requesting record of person it intends to insure, now insures, or has rejected for insurance.
C = Credit Business Legitimate Business need in connection with a business transaction initiated by the driver

L = Attorney representing driver identified in Section C Driver must complete Section E
C = Credit Business Legitimate Business need in connection with a business transaction initiated by the driver

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).
NAME: LAST
FIRST
INITIAL
CITY
STATE
ZIP CODE
PHONE NUMBER
PHONE NUMBER
MONTH
DAY
YEAR
PRINTED NAME OF REQUESTER
DRIVER RELEASE
NAME OF DRIVER
the Department of Transportation to furnish a copy of my PA Driver's
will use the driver record abstract(s) required pursuant to Section 6114 of the Pennsylvania Vehicle Code, for the purpose checked above only 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 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 4903(a2) (relating to false swearing), which shall include punishment of a fine not exceeding $5,000, or to a term of imprisonment of not more than two years, or both.
DATE

MonthDayYear
Date
MICROFILM
TYPE OF DOCUMENT
DATE OF VIOLATION

MonthDayYear
Date
Title
(see list of available documents below)
Documents Available:
SIGNATURE OF PERSON ADMINISTERING OATH
- Citations
- Court Certifications
- Applications
- License Renewals
- Judgments
- Suspension Credit Affidavits
- Ignition Interlock Removal Letter
- Suspension/Revocation Letters
- Restoration Letters
- Rescind Letters
- Department Hearing or Exam Notice
S E
A NOTARIZATION L
SIGN IN PRESENCE OF NOTARY
INSTRUCTIONS
1.To request your own record, complete Sections A & C only. Notarization is NOT required. 2.To request a record other than your own, complete Sections A, C, and D. Section E must contain the driver's signature if block

B, E or L is checked in Section D. If the Requester is obtaining the information on behalf of someone else, Section B must also be completed.

3.PRINT OR TYPE all requested information on the front of the form. Submitting ONLY a name and address does not provide enough information for a proper search of the driver files. 4.A non-refundable fee is required for each request. If the Bureau has no record for the information requested or the data supplied is insufficient, the fee will be applied to the cost of the search. 5.If requesting a microfilm copy of a document, also complete Section F. You must be specific in providing the type and date of the document. If there are several citations on the record, the cost is $10.00 per citation. You need to provide the date of the violation/action to clearly identify the citation(s) requested. 6.Check the type of record requested at the top of the form and make check or money order payable to "PennDOT." DO NOT SEND CASH. Attach your check or money order and send to:

For overnight and other special mail:

BUREAU OF DRIVER LICENSING DRIVER RECORD SERVICES P.O. BOX 68695 HARRISBURG, PA 17106-8695

BUREAU OF DRIVER LICENSING DRIVER RECORD SERVICES 1101 SOUTH FRONT STREET 3RD FLOOR HARRISBURG PA 17104-2516
DESCRIPTION OF INFORMATION AVAILABLE
BASIC INFORMATION . . . . Includes name, address, driver number, date of birth and class of license.

Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the past 3 years from the date request is processed.

Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the past 10 years from the date request is processed. A 10-year record is for employment purposes only.

FULL HISTORY . . . . . . . . .Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the ($11.00 fee)complete history of the driver on file in Pennsylvania .

Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for

the ($36.00 fee) complete history of the driver on file in Pennsylvania certified by the Department.

Copies of documents retained by the Department are available for purchase from the microfilm file. You must be

specific ($11.00 fee) as to the type of document and the date of the violation/action.

Copies of doc uments from the microfilm file that have been certified by the
IMPORTANT INFORMATION CONCERNING THE USE OF DRIVER INFORMATION
- procedures to protect the confidentiality of these records.
- Driver record information can only be used for the purpose stated in Section D.
- Driver record information cannot be sold, assigned, or otherwise transferred to any party, other than the End User.
- PennDOT retains exclusive ownership of all driver record information and the Requestor/End User shall not combine and/or link in with any other data on any database except as may be required by law.
- The driver record information cannot be used for direct mail advertising or any other type or types of mail or mailings.
- The driver record information cannot be disseminated or published on the Internet without the express written permission of PennDOT.
- PennDOT reserves the right to audit each request for driver record information. If the Requestor/End User is found to have requested driver record information for an unauthorized purpose, access to Pennsylvania driver record information will be terminated. Visit us at www.dmv.pa.gov or call us at: 717-412-5300 ♦ TDD: 711
Driver record information is confidential and restricted information and the Requestor/End User is responsible for establishing

Businesses who obtain driver records for the purpose of employment or insurance are now able to obtain and print these records, in real time, through our enhanced Online Services. If you are an employer or insurance company/agent and are interested in becoming an authorized Online business user, please

visit our website at www.dmv.pa.gov and click on "Online Business Services" for more information.
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DL-503 (7-19)

REQUEST FOR DRIVER INFORMATION

DO NOT SEND CASH • SEE REVERSE FOR INSTRUCTIONS

A REQUESTER INFORMATION

END USER OF INFORMATION BEING REQUESTED

AFFIDAVIT OF INTENDED USE

SIGNATURE

NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD

DRIVER INFORMATION

MICROFILM

TYPE OF DOCUMENT

Documents Available:

S E

A NOTARIZATION L

SIGN IN PRESENCE OF NOTARY

INSTRUCTIONS

DESCRIPTION OF INFORMATION AVAILABLE

IMPORTANT INFORMATION CONCERNING THE USE OF DRIVER INFORMATION