REQUEST FOR DRIVING RECORD 21080
User Manual: 21080
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REQUEST FOR DRIVING RECORD
(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
