By Fax to:
By Mail to:
Client Information
Client Name:
Master Number:
Client Signature:
Driver Abstract Request
(for Out of Province use only)
NOTE: Please fax completed form to: (902) 424-0602. All requests will be processed within three business days and
in the order in which they are received. If all requested information is not provided, your Driver Abstract request will
not be processed. For further information you may contact us at ( 902 ) 424-5851 or 1-800-898-7668.
Date of Birth: / /
Day
Daytime Phone #:
Date:
Please check manner to receive Driver Abstract (Choose one):
(include area code)
Street:
City/Town:
Province: Postal Code:
Terms of Credit Card Use: By signing this form, I authorize Access NS / RMV to use the credit card
details below to process payment for the attached batch of transactions. Access NS / RMV will destroy the credit
card information after this batch of transactions is processed and will not use for any other purpose.
Credit Card Holder Signature:
Date:
(Cut and shred this section after processing)
Credit Card Payment Details
MasterCard (16 digits)
American Express (15 digits)
Account Number:
Month
Year
Name:
Visa (16 digits)
Card Holder Name:
Expiry Date:
M M YY
Reason Driver Abstract is required:
Choose One (For more information on abstract types visit: http://novascotia.ca/sns/rmv/licence/abstracts.asp )
To forward your abstract to an insurance company or employer on your behalf we require either:
Contact Name: Or Policy / Ref Number:
Daytime Phone #:
Employment Insurance
Client/Taxi Licence Other Motor Vehicle Department
click to sign
signature
click to edit
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click to sign
signature
click to edit
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