Form PS2506-03 "Authorization Form (Grant Access to Record)" - Minnesota

What Is Form PS2506-03?

This is a legal form that was released by the Minnesota Department of Public Safety - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2018;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PS2506-03 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS2506-03 "Authorization Form (Grant Access to Record)" - Minnesota

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
445 Minnesota Street,Saint Paul, MN 55101-5161
Phone: (651) 296-2940 TTY: (651) 282-6555 Web: dvs.dps.mn.gov
Date:
Aut ho r iz a ti on F or m ( G ra nt Ac cess to R ecord)
This request form can only be used when obtaining records from the DVS Records Counter located in St. Paul.
I,
,
First Name
Middle Name
Last Name
hereby authorize
First Name
Middle Name
to obtain and/or pick up the following item(s) and/or
Last Name
record information from Driver and Vehicle Services:
Record Type:
Motor Vehicle
Driver's License
Limited Driver's License
Other:
Authorizer's Signature
X
The Driver Privacy Protection Act (DPPA) is enforced by the U.S. Department of Justice, which may seek civil and
criminal penalties for improperly obtaining, disclosing or using personal information from a motor vehicle record for a
purpose not permitted by the DPPA. In addition, private citizens may also seek civil damages in Federal Court.
Certification I (we) certify that the information and statements on this request are true and correct, comply with the
provisions of the Federal Driver's Privacy Protection Act and understand that the willful, unauthorized disclosure of
information obtained from these records for a purpose other than stated on this request, or the sale or other
distribution of the information to a person or organization not disclosed in this request may result in penalties imposed
under Title 18 U.S.C. Section 2724.
PS2506-03 (11/18)
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
445 Minnesota Street,Saint Paul, MN 55101-5161
Phone: (651) 296-2940 TTY: (651) 282-6555 Web: dvs.dps.mn.gov
Date:
Aut ho r iz a ti on F or m ( G ra nt Ac cess to R ecord)
This request form can only be used when obtaining records from the DVS Records Counter located in St. Paul.
I,
,
First Name
Middle Name
Last Name
hereby authorize
First Name
Middle Name
to obtain and/or pick up the following item(s) and/or
Last Name
record information from Driver and Vehicle Services:
Record Type:
Motor Vehicle
Driver's License
Limited Driver's License
Other:
Authorizer's Signature
X
The Driver Privacy Protection Act (DPPA) is enforced by the U.S. Department of Justice, which may seek civil and
criminal penalties for improperly obtaining, disclosing or using personal information from a motor vehicle record for a
purpose not permitted by the DPPA. In addition, private citizens may also seek civil damages in Federal Court.
Certification I (we) certify that the information and statements on this request are true and correct, comply with the
provisions of the Federal Driver's Privacy Protection Act and understand that the willful, unauthorized disclosure of
information obtained from these records for a purpose other than stated on this request, or the sale or other
distribution of the information to a person or organization not disclosed in this request may result in penalties imposed
under Title 18 U.S.C. Section 2724.
PS2506-03 (11/18)