Fillable DL Emergency Contact REV (Minnesota)

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DL Emergency Contact REV (Minnesota)

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Emergency Contact Information
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
If you have previously submitted emergency contact information and wish to update your emergency contact information by mail
please send it to: Driver and Vehicle Services 445 Minnesota Street Suite 183 St. Paul, MN 55101-5183
I wish to add emergency contact information
I wish to change existing emergency contact information
I wish to remove existing emergency contact information
DL Number (OMIT DASHES)
Requester's name
Emergency Contact Name
Emergency Contact Name
Emergency Contact Name
Contact Phone Number
Contact Phone Number
Contact Phone Number
I request that this entry is placed on my driving record to alert law enforcement personnel that I have emergency contacts. I
understand this entry will remain on my record until I send a request to Driver and Vehicle Services to remove or amend the
information.
Requestor's Signature
Date
Rev. 12/2019
Tennessen Warning
What is the purpose of supplying emergency contact information?
The information collected on this form is to add emergency contact(s) to your driver's license or identification card record
pursuant to Minnesota Statutes, section 171.12, subdivision 5b.
Am I required to provide emergency contact information?
You are not required to provide emergency contact information to add to your driver's license or identification card.
What will happen if I do not provide emergency contact information?
If you do not provide emergency contact information, DVS will be unable to add emergency contacts to your driver's license
or identification card record. If you are involved in an emergency, law enforcement will not contact anyone on your behalf.
Who will have access to the emergency contact information?
Your emergency contact information will only be accessible to law enforcement agencies to notify the individual(s) listed on
your driver's license or identification card record regarding an emergency. See Minnesota Statutes, section 171.12,
subdivison 5b(c).
Initial Applications must be submitted in person to your local driver's license agent office with a credential application
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DL Emergency Contact REV (Minnesota)

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Completed 14 July 2020

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