of
Name of the Person / Organization Receiving the Driver Abstract
Address
Driver Abstract Consent
A "driver abstract" is the product name under which the Alberta Government releases specific information
from a person's driving record, which contains:
and I give consent for my
.
from the date this form is signed, to:
declare that my Driver's Licence Number is:
In accordance with the Alberta Motor Vehicle Information Regulation (AMVIR), choose one of the following subsections:
This information is being collected for the purposes of Motor Vehicle records in accordance with the Traffic Safety Act. Questions about the collection of this information can
be directed to the Freedom of Information and Protection of Privacy Coordinator for
the Alberta Government, Box 3140, Edmonton, Alberta T5J 2G7, (780) 427-7013.
REG3387 (2005/11)
5(1)(a) Driver abstract released to a person known by myself
I acknowledge that the above person is personally known to me, is not acting as an agent or employee of any other person in
this transaction, and is not compensated in any manner for receiving or transferring the driver abstract to myself.
NOTE: This cannot be faxed.
5(1)(b)(iii) Driver abstract released to my employer or prospective employer
NOTE: This can be faxed.
3 Year
5 Year 10 Year
5(1)(b)(v) Driver abstract released to a lawyer representing me
NOTE: This can be faxed.
or
I agree that in no event will the Province of Alberta or its Registry Agents be liable for any damages or losses, however
caused, in respect to any defect, error or omission in the driver abstract, or use of the driver abstract by the person
receiving it.
Signature Date
PART 1
z Name
z Address
z Date of Birth
z Height
z Weight
z Sex
z MVID Number
z Licence Numberz Class
z Issue Date z Current Demerit Points
z Suspended Status
z Reinstatement
conditions (if any)
z Expiration Date
month by name, day, year
,
of ,
Name Address
I,
request the driver abstract, as mentioned above, to be faxed to
I / We agree that in no event will the Province of Alberta or its Registry Agents be liable for the driver abstract after it has
been faxed to the above number.
Signature of Employer or Lawyer Date
of
.
Name of Employer or Lawyer Address
I / We,
Area Code Fax Number
PART 2 - Declaration for Faxing (This does not apply to subsection 5(1)(a) above)
,
z List of violations (Descriptions, Demerit / Merit Points and Suspension Term)
my Date of Birth is:
,
driver abstract to be released, for a period of one year
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