Pennsylvania Motor Vehicle Records Release Form Required
INSTRUCTIONS
Specific release form (DL 503) version 7-19 is required when ordering Pennsylvania motor vehicle
records. Please have your applicant complete “SECTION C” and “SECTION E” of the attached PA MVR
consent form. Please leave all other fields blank. Return the signed release form to BCS Background
Screening, LLC by uploading to applicant's profile in your secure account and ALSO email to:
support@usabackground.com or fax at 305-402-3181
Note: that the turnaround time for Pennsylvania MVRs is approximately 1-3 weeks.
Pennsylvania Release Form Instructions:
A - REQUESTOR INFORMATION: LEAVE BLANK
B - END USER OF INFORMATION BEING REQUESTED:
Complete this section with your business information.
NOTE: PO Boxes are not acceptable addresses, need to provide physical location of
business/organization.
C - DRIVER INFORMATION – DRIVER COMPLETES THE FOLLOWING
a. Driver Last Name, First Name
b. Driver Address Information
c. Driver Phone Number
d. Driver’s Date of Birth
e. Driver License Number
D - AFFIDAVIT OF INTENDED USE – Pre Filled WITH Employment Purposes Only
E - DRIVER RELEASE – DRIVER COMPLETES THE FOLLOWING
o Driver Full Name –
o Name of Person/Company – LEAVE BLANK
o Driver Signature and Date – Please have applicant/employee sign and date their
signature. Note: Signature must have a date, or the release form will be rejected.
F – MICROFILM – LEAVE BLANK
DO NOT SIGN or NOTARIZE Printed name of requester below section D
Intended Use of the Information Requested: CHECK ONLY ONE
❏ B = Driver Release (Driver must complete Section E.)
❏ C = Credit Business (Legitimate Business need in connection with a business
transaction initiated by the driver.)
❏ C = Credit Potential Investor, Server or Current Insurer (In connection
with an assessment of the credit/payment risks associated with an existing credit
obligation.)
❏ E = Employment (To support the hiring or the continuation of employment. Driver
must complete Section E.)
❏ R = Insurance Company requesting record of person it intends to insure,
now insures, or has rejected for insurance.
❏K = Court Order must be attached. (A subpoena issued in compliance with
Pa. R.C.P. 4009.21 will be accepted in lieu of a court order).
❏ L = Attorney representing driver identified in Section C (Driver must complete
Section E.)
CHECK (✔) ONE ONLY:
❑ BASIC INFORMATION: $11.00 FEE (Driver history is
not included)
❑ 3 YEAR DRIVER RECORD: $11.00 FEE
❑ FULL HISTORY: $11.00 FEE
❑ CERTIFIED DRIVER RECORD:
$36.00 FEE
❑ COPY OF DOCUMENT FROM FILE (MICROFILM): $11.00 FEE
❑ 10 YEAR DRIVER RECORD: $1
1.00 FEE (Employment Purposes Only)
❑ CERTIFIED COPY OF DOCUMENT FROM FILE: $36.00 FEE
You may obtain a copy of your own 3 year or 10 year Driving Record on PennDOT'S website at www.dmv.pa.gov
REQUESTER INFORMATION B END USER OF INFORMATION BEING REQUESTED
X
A
NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD
AFFIDAVIT OF INTENDED USE
D
MONTH DAY YEAR
DRIVER INFORMATION
NAME: LAST FIRST INITIAL
ADDRESS
CITY
STATE ZIP CODE
PHONE NUMBER
DRIVER NUMBER
DATE OF BIRTH
C
MESSENGER NO.
SIGNATURE
SIGNATURE OF REQUESTER
PRINTED NAME OF REQUESTER
E
DRIVER RELEASE
I _______________________________________ hereby request
the Department of Transportation to furnish a copy of my PA Driver's
Record to ____________________________________________
NAME OF DRIVER
NAME OF PERSON/COMPANY
SIGNATURE OF DRIVER DATE
X
TYPE OF DOCUMENT DATE OF VIOLATION
(see list of available documents below)
Documents Available:
• Citations • Ignition Interlock Removal Letter
• Court Certifications • Suspension/Revocation Letters
• Applications • Restoration Letters
• License Renewals • Rescind Letters
• Judgments • Department Hearing or Exam Notice
• Suspension Credit Affidavits
F
MICROFILM
X
P.O. Box number may be used in addition to the actual address, but cannot be
used as the only address.
SUBSCRIBED AND SWORN
TO BEFORE ME: MONTH DAY YEAR
NOTARIZATION
SIGNATURE OF PERSON ADMINISTERING OATH
S
E
A
L
X
SIGN IN PRESENCE OF NOTARY
REQUEST FOR DRIVER INFORMATION
DO NOT SEND CASH • SEE REVERSE FOR INSTRUCTIONS
DL-503 (7-19)
Bureau of Driver Licensing • P.O. Box 68695 • Harrisburg, PA 17106-8695
I hereby Certify that _______________________________________________
will use the driver record abstract(s) required pursuant to Section 6114
of the Pennsylvania Vehicle Code, for the purpose checked above only
and no other reason. This affidavit is filed in compliance with Section
607 of the Fair Credit Reporting Act. I/We have read and signed this
form after its completion, and I/We swear or affirm that the statements
made herein are true and correct, and that any statement made on or
pursuant to this form is subject to the penalties of 18 Pa C.S. Section
4903(a)(2) (relating to false swearing), which shall include punishment
of a fine not exceeding $5,000, or to a term of imprisonment of not more
than two years, or both.
_______________________________________________________________
Title ___________________________________________________________
NAME/COMPANY NAME/COMPANY
ADDRESS ADDRESS (P.O. Box not acceptable), need to provide physical location of business/residence
CITY STATE ZIP CODE CITY STATE ZIP CODE
DAYTIME TELEPHONE NUMBER (REQUIRED) _________________________________ DAYTIME TELEPHONE NUMBER (REQUIRED) _____________________________________
RELATIONSHIP TO DRIVER (REQUIRED) _____________________________________________ RELATIONSHIP TO DRIVER (REQUIRED)
______________________________________
SambaSafety Account #
✔
Samba Safety
8814 Horizon Blvd Suite 100
Albuquerque
NM
87113
Vendor
✔