Occupational and Business Licensing
555 Wright Way
Carson City, Nevada 89711-0100
(775) 684-4690
www.dmvnv.com
CONSENT AND WAIVER TO OBTAIN BANKING RECORDS
I, , as a principal operator of
,
hereby consent and agree pursuant to Section 239A.090 of the Nevada Revised Statutes, the Nevada Department of
Motor Vehicles, Compliance Enforcement Division may obtain duplicates of deposits/withdrawal transaction and account
balance documents and checks as referenced below:
Deposit/withdrawal transaction and account balance documents and checks contained in:
Bank Name Account Number ,
Branch Name and Address
State of Nevada, for the period beginning , 20 , and continuing in effect
through , 20 ,
, a Nevada
Business Name
business licensed as a has an active business license .
Type
Number
I, , provide this consent to obtain referenced banking records with the understanding
I have the right at any time to revoke this authorization.
I, , understand these records will be used only in the furtherance of the Nevada
Department of Motor Vehicles, Compliance Enforcement Division regulatory duties imposed under Chapters 445B, 481,
482, 483 and 487 of the Nevada Revised Statutes. Furthermore, that the referenced records will only be used for
administrative purposes and shall not be divulged to any other person, entity, or governmental agency except as provided
by law.
Except as otherwise provided, I , hereby waive any objection or legal right which may
prevent the disclosure of the referenced records and hold harmless the State of Nevada, its agents, officers and
employees, as well as, the financial institutions referenced above and their agents and employees from any injury or
damage which may occur by reason of disclosure of the referenced records. A photocopy of this form is as valid as the
original. I declare under penalty of perjury that the foregoing is true and correct.
Signature of Applicant Date
Title
day of ,
Notary Public or Authorized Nevada DMV Representative
OBL287 (9/2008)
(Notary Seal)
State of Nevada County of
Subscribed and sworn before me this
