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FAX
this completed form to (727) 467-0918.
Please
print clearly to avoid a delay in processing. Your
personal information
is
kept strictly confidential and is not shared with third parties. Privacy
Policy
Subject
Information
First
Name: ______________________ Last Name:______________________
Driver License Number: _____________________________________________
State:
________ Date of Birth:____________________ SSN: ______________
I
hereby authorize the Pennsylvania Division of Motor Vehicles to release my
driving
record to the AmerUSA Corporation's DMV
Driving Record Search dept.
This
authorization is for a one-time use only. Future DMV records will require a
new
authorization.
Subject
Signature: _____________________________ Date:_______________
CIRCLE A DELIVERY METHOD & PERMISSIBLE PURPOSE:
1)
FAX
- Please allow 1-3 business
days to receive your record abstract.
2)
US
MAIL - Please allow 5-7 business days to receive your record abstract.
Purpose
for ordering report (circle one):
Court Order -
Consumer's Request - Credit
Extension - Employment -
Business Need
Account Review -
License Eligibility -
Existing Credit Obligation -
Child Support
Your
Billing
Information
First Name: ______________________ Last Name:______________________
Address: _________________________________________________________
City: ________________________ State: _______ Zip Code: ______________
Phone:
________________________ Fax: _____________________________
Email Address:____________________________________________________
THE
CHARGE FOR THIS DMV RECORD IS $ 39.95
Your
Credit
Card Information (Visa or MasterCard Only)
We
DO NOT ACCEPT American Express or Discover Card.
Account Number: ___________ - ____________ - ___________ - ___________
Expiration Date: _________ / ________ (mm/yy)
Service
Agreement
I
agree to abide by all applicable local, state and federal laws with regard
to the report(s) I am ordering
today
and will not share this information with any third parties or display it
publicly. I also understand
that
I must have the subject person's permission to view his/her DMV driving
record. Under penalty of
perjury,
I swear that I am in full compliance with all applicable laws and agree to
hold DMV Driving
Record
Search (an AmerUSA Corporation Florida Company) harmless in the event I
misuse this
information.
Understanding all that has been disclosed, as the authorized cardholder of
the credit card
indicated
above, I grant permission to have it charged for the total amount of $39.95.
PLEASE
VERIFY ALL OF THE INFORMATION PROVIDED ABOVE, ESPECIALLY
THE
DRIVER LICENSE NUMBER. FAILURE TO PROVIDE A CORRECT DL # WILL
RESULT
IN NO RECORD AND YOUR CREDIT CARD WILL STILL BE CHARGED.
ALL
ORDERS ARE DISPATCHED TO THEIR RESPECTIVE STATE DMV
RESEARCHERS
IMMEDIATELY. NO CANCELLATIONS OR CHANGES CAN BE
MADE
AFTER YOU FAX YOUR ORDER. EVEN THOUGH WE STRIVE TO PROVIDE
RESULTS
IN THE TIME FRAME INDICATED, DELIVERY TIMES MAY VARY
ACCORDING
TO EACH JURISDICTION.
Signature: __________________________________
Date:______________
Print Name: __________________________________
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