Authorization Form (Grant Access to Record)
First Name Middle Name Last Name
I,
Date:
hereby authorize
Last Name
Middle Name
First Name
to obtain and/or pick up the following item(s) and/or
record information from Driver and Vehicle Services:
Record Type:
Motor Vehicle
Driver's License
Limited Driver's License
Other:
Authorizer's Signature
PS2506-03 (11/18)
,
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street,Saint Paul, MN 55101-5161
Phone: (651) 296-2940 TTY: (651) 282-6555 Web: dvs.dps.mn.gov
X
The Driver Privacy Protection Act (DPPA) is enforced by the U.S. Department of Justice, which may seek civil and
criminal penalties for improperly obtaining, disclosing or using personal information from a motor vehicle record for a
purpose not permitted by the DPPA. In addition, private citizens may also seek civil damages in Federal Court.
Certification I (we) certify that the information and statements on this request are true and correct, comply with the
provisions of the Federal Driver's Privacy Protection Act and understand that the willful, unauthorized disclosure of
information obtained from these records for a purpose other than stated on this request, or the sale or other
distribution of the information to a person or organization not disclosed in this request may result in penalties imposed
under Title 18 U.S.C. Section 2724.
This request form can only be used when obtaining records from the DVS Records Counter located in St. Paul.
