REQUEST FOR DRIVING RECORD 21080

User Manual: 21080

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R EQUEST F OR D RIVING R ECORD
(Fee: $20.00)
COURT RECORDS P.O. BOX 55896

BOSTON, MA 02205

www.massrmv.com

Please print clearly.
Requestor Information
Does the Driving Record need to be certified (imprinted with a Registrar’s stamp)?

Yes

No

Certified requests are only processed by the Court Records Department at 136 Blackstone Street, Boston, MA 02116.
If mailing your request, use the P.O. Box above and include a check or money order payable to MassDOT.

Name of Requestor:

Date:

Address of Requestor:
City:

State:

Zip:

If requesting as an authorized representative of:
Name of Company/Agency:
Company/Agency Address:
Requests a Driving Record for the following person:
All information MUST be supplied.
Requested Driver Information
Name:
Last

First

Middle or Initial

Date of Birth:
Month

Day

Year

Driver’s License Number:

Note: If you do not know the Driver’s License Number and believe that you may qualify as a permitted user
of personal information from motor vehicle records under the Driver Privacy Protection Act, 18 U.S.C 2721
et seq, please indicate this to the RMV representative.

T21080-0315
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Title                           : REQUEST FOR DRIVING RECORD
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