Get PA DL-503 2023-2024

DL-503 7-11 request for driver information The most current version of this form can be found at www. dmv*state. pa*us PLEASE TYPE OR PRINT IN BLUE OR BLACK INK DO NOT SEND CASH see reverse for instructions D E PA R T M E N T O F T R A N S P O R TAT I O N CHECK ONE ONLY BASIC INFORMATION 5. 00 FeE Driver history is not included 3 YEAR Driver RECORD 5. 00 Fee Bureau of Driver Licensing P. O. Box 68695 Harrisburg PA 17106-8695 Full History 5. 00 Fee CERTIFIED DRIVer RECORD 10. 00 Fee Copy of document from file microfilm 5. 00 Fee CERTIFIED COPY OF document from file 10. 00 Fee You may obtain a copy of your own 3 year 10 year and/or Full History Driving Record on PennDOT S website at www. dmv*state. pa*us A REQUESTER INFORMATION B END USER OF INFORMATION being requested NAME/company name/company ADDRESS address P. O. Box not acceptable need to provide physical location of business/residence CITY STATE ZIP CODE city state zip code DAYTIME TELEPHONE number required relationship to driver required D AFFIDAVIT OF INTENDED USE signature Intended Use of the Information Requested CHECK ONLY ONE X B Driver Release Driver must complete Section E* C Credit Business Legitimate Business need in connection with a business C Credit Potential Investor Server or Current Insurer In connection CITY NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD C DRIVER INFORMATION NAME LAST FIRST STATE INITIAL ZIP CODE transaction initiated by the driver. phone number date of birth MONTH DRIVER NUMBER DAY YEAR E driver release I hereby request name of driver the Department of Transportation to furnish a copy of my PA Driver s Record to name of person/company signature of driver date F microfilm TYPE OF DOCUMENT date of violation with an assessment of the credit/payment risks associated with an existing credit obligation* E Employment To support the hiring or the continuation of employment. Driver must complete Section E* R Insurance Company requesting record of person it intends to insure now insures or has rejected for insurance. 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. L Attorney representing driver identified in Section C Driver must complete Section E* I hereby Certify that PRINTED NAME OF REQUESTER 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 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 than two years or both.