AUTHOrizATiON FOr rElEAsE OF MOTOr ... - …

1 DriVEr iNFOrMATiONLast NameFirst NameMiddle NamePA DL or Photo ID#Date of BirthVEHiClE iNFOrMATiONOwner Last NameFirst NameMiddle NameDate of BirthCo-Owner Last NameFirst NameMiddle NameDate of BirthVehicle Identification NumberTitle NumberRegistration Plate NumberrEAsON FOr iNQUirYoCheck on suspension status/print restoration requirements message during processing of application. Checking on:oAlready renewedoCommercial DriveroOut-of-State or Immigration & Naturalization Services (INS) Citizenship & Immigration Services (USCIS) indicatoroOther (specify): _____oCheck on work previously submitted to PennDOT by this agent/messenger. NOTE:If checking on multiple applicationssubmitted, list additional records on the back of this record accessed (list correct record information): _____oQuality control of work processed on the following date(s): _____oOther (provide a brief description concerning the type of information required and the purpose for which it will be used): _____DriVEr / VEHiClE OWNEr / lEssEE rElEAsEI hereby request PennDOT to furnish to _____information regarding my Pennsylvania driver and/or vehicle record to be used for the purpose indicated in Section C.

2 I further certifythat the vehicle in Section B is titled and/or registered in my name, and I am inquiring through an Agent Service for status on the _____ _____ _____ _____AGENT / MEssENGEr iNFOrMATiON (Complete for permissible inquiries without driver/owner/lessee rElEAsE .)MV-753 (7-15) AUTHOrizATiON FOr rElEAsE OF MOTOrVEHiClE/DriVEr rECOrD iNFOrMATiON(FOR USE BY AUTHORIZED AGENTS AND/OR MESSENGERS ONLY)For Department Use OnlyBureau of MOTOr Vehicles 1101 South Front Street Harrisburg, PA 17104 NOTE:This form must be maintained in the office of the requester for three years and is subject to PennDOT audit withoutprior notification.

3 Agents must obtain the customer's signature of AUTHOrizATiON in order to access any driver and/or vehicleinformation needed to assist in a MOTOr vehicle or driver license License Inquiry - Complete Sections A, C, and D or E(NOT BOTH).oMotor Vehicle Inquiry - Complete Sections B, C, and D or E (NOT BOTH).ABCDEP rinted Name of Driver / Vehicle Owner / LesseeSignature of Driver / Vehicle Owner / LesseeDatePrinted Name of Vehicle Co-Owner / LesseeSignature of Vehicle Co-Owner / LesseeDatePrinted Name of Requester_____ _____ _____Printed Name of Agent / Messenger Employee Accessing Record(s)User IDSignature of Agent / Messenger Employee Accessing Record(s)DateDIN / Messenger #Visit us at