DPS303RM-03 05/07
State of Oklahoma
Department of Public Safety
Consent to Release Record(s)
Driver Name: ____________________________________ D.L. #:____________________ DOB: __________
(AS SHOWN ON LICENSE)
By signing below, I voluntarily give consent to the Oklahoma Department of Public Safety or any Motor License
Agent to release the following record(s) indicated by my signature below to be released by the Department of Public
Safety or any Motor License Agent, their agents and employees, to the person, company, corporation or legal entity
listed below.
I understand, as required by the Federal Driver Privacy Protection Act (DPPA), 18 U.S.C. Section 2721, the
Oklahoma Department of Public Safety or any Motor License Agent will not release personal information from my
driver record unless I consent by waiving my right to privacy under the DPPA; OR, unless the Department is
required by DPPA to release personal information without my consent, such as in connection with matters of
safety, theft, emissions, product alterations, recalls, advisories, certain federal laws; or, unless the DPPA authorizes
the Department to release it, such as to governmental entities, courts, insurance companies, and to others specified.
Check one of the following:
G MVR summary;
G Other record (SPECIFY): __________________________________________________________________
Release Record/Information to: ________________________________________________________________
____________________
__________________________________________
DATE
DRIVER’S SIGNATURE OF CONSENT
***THIS FORM & PHOTO ID REQUIRED TO OBTAIN RECORD***
________________________________________
__________________________________________
PRINTED NAME OF RECIPIENT OF RECORD
SIGNATURE OF RECIPIENT OF RECORD
__________________________________________________________________________________________
ADDRESS OF RECIPIENT OF RECORD
Mail completed form along with appropriate fees to:
Fees for:
Department of Public Safety
Dr