Long Form Request

Long Form Request

To request copies of the DOT Long Form.
Who is making this request?*

DriverEmployer
Name of person making request:

First NameLast Name
Full Legal Name of Driver*

First NameLast Name
D.O.B.*

MonthDayYear
Last 4 digits of Drivers License*
What year was the exam performed?
If you know the month, that helps too!
Requests can be processed via Fax or Email, please fill out the respective box.
Recipients Email
Recipients Fax

Area CodePhone Number
Authorization

I am personally authorizing the release of my own drivers examination report. I understand that this information can either be sent via fax or email.
Employer Authorization

I have a signed release on file authorizing this request from the employee listed above. This report can either be sent via fax or email.
Signature of Requesting Party*

Clear
Use mouse or touch screen to capture signature
If you do not see a confirmation page, your request was not processed. Please try again, or send us an email.
Should be Empty: