Drivers Disclosure Form - Transit Driver Notification System printable pdf download

TRANSIT DRIVER NOTIFICATION SYSTEM

DRIVER’S DISCLOSURE FORM

This form is to be used and kept by your agency in compliance with the Federal Driver’s Privacy Protection Act and

NC General Statute 20-43.1. A copy for each driver must be kept on file for five years.

Effective September 13, 1997, all motor vehicle records are subject to the Federal Driver’s Privacy Act (FDPPA) and General Statute 20-43.1.

The FDPPA and the GS 20-43.1 require that personal information in the Division of Motor Vehicles records be closed to the public. Personal

Information from these records may be released to individuals or organizations that qualify under one of the fourteen (14) exceptions listed on the

back of this form. These exceptions are summarized statements of permissible uses.

Name of Driver:

_____________________________________________________________________________

DL#:

State of DL:

DL Class:

________________________

__________

DL Expire Date:

Yes

Date of Birth:

______________ CDL

____________________________

Address:

____________________________________________________________________________________

City: _______________________ State: _____________ Zip Code: _____________________________

Telephone #

Hire Date:

:_____________________________

__________________________________________

Department:

Work Phone #:

________________________________

____________________________________

Job Title:

____________________________________________________________________________________

By signing this form, you are granting the company access to your personal information under exception number 13 of the FDPPA and

GS 20-43.1.

NAME OF COMPANY/AGENCY:

____________________________________________________________

SIGNATURE OF DRIVER:

DATE:

__________________________________

__________________________

My signature on this document acknowledges that I understand that improper release of Information and/or false representation to gain

information form the DMV’s records is prohibited and is subject to civil action.

COMPANY/AGENCY: _________________________________________________________________

NAME OF REQUESTER/CONTRACT: ___________________________________________________

REQUESTER’S SIGNATURE: ______________________________DATE: ______________________

My signature on this document acknowledges that I understand that improper release of information and/or false representation to gain

information from the DMV’s records is prohibited and is subject to civil action.

COMPANY/AGENCY: _________________________________________________________________

COMPANY/AGENCY APPROVAL AUTHORITY: _________________________________________

TITLE: ______________________________________________________________________________

SIGNATURE: ____________________________________________ DATE: _____________________

*****INCLUDE COPY OF DRIVERS LICENSE*****

Revised, 6/20/2016

Drivers Disclosure Form - Transit Driver Notification System

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