Driver Abstract Request Form
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1Driver Abstract Request Form
DRIVER INFORMATION
Name: ___________________________________________________________________________________________
Last Name
First Name
Middle Initial
Driver’s Licence Number: ____________________________________ Date of Birth: ________/_________/__________
Month
Day
Year
Telephone Number: ______________________________ Return Fax No. or Address: ___________________________
Type of Abstract Requested:
Driver Abstract
Commercial Driver Abstract
AUTHORIZATION TO DISCLOSE DRIVER ABSTRACT
I hereby authorize Manitoba Public Insurance, to disclose my Driver Abstract to the individual/company noted below, in person,
by facsimile or by mail.
Individual/Company: ________________________________________________________________________________
Address: _______________________________________________ Fax Number: _______________________________
EMPLOYEE AUTHORIZATION
I hereby authorize Manitoba Public Insurance to disclose my Driver Abstract to
_________________________________________________________________________________________________
Employer
for the duration of my employment with said employer or until such time that I advise Manitoba Public Insurance, in writing, to
revoke this authorization.
Address: _______________________________________________ Fax Number: _______________________________
DRIVER’S SIGNATURE* ________________________________________________ DATE ________________________
*A photocopy of this signed authorization shall have the same authority as the original.
PAYOR INFORMATION – IF DIFFERENT FROM ABOVE DRIVER
Individual / Company Name: ____________________________________________________________________________
Company Contact Name: ______________________________________________________________________________
Contact Phone Number: _________________________ Contact Fax Number: ___________________________________
IF REQUESTED VIA MAIL (TO ADDRESS BELOW) OR FAX (TO FAX BELOW) PLEASE SEND $10.00 PAYMENT PER DRIVER
ABSTRACT BY CHEQUE OR MONEY ORDER, PAYABLE TO MANITOBA PUBLIC INSURANCE OR PROVIDE THE FOLLOWING
CREDIT CARD INFORMATION .
VISA / MasterCard Number: __________________________________________________________________________
Card Expiry Date: _________________Card Holder Signature: ______________________________________________
Mail/Fax Request To:
OFFICE USE
ONLY:
Manitoba Public Insurance
Driver Records and Suspensions
Fee Paid
Box 6300
Winnipeg, MB R3C 4A4
$10
Fax: 204-954-5357
FOR MORE INFORMATION CALL: 204-985-0980 or TOLL FREE: 1-866-323-0543
REV (04/15)
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Parent category: Business