Form PS32005 "Crash Victims Memorial Wall - Participation Release" - Minnesota

What Is Form PS32005?

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 August 1, 2011;
  • 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 PS32005 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 PS32005 "Crash Victims Memorial Wall - Participation Release" - Minnesota

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
Cra sh V ict i ms Me m o r i al Wa l l - P art i c ip ati on R ele ase
Please submit this signed release form, with photograph(s), to your local DVS exam station and/or to the Crash
Victims Memorial Wall in Saint Paul, MN. (Addresses on back.) Photographs may be displayed in one or both
locations.
Behaviors such as operating a motor vehicle while impaired by alcohol or drugs, traveling at unsafe speeds, and
engaging in aggressive and distracted driving cause hundreds of deaths and thousands of injuries annually on
Minnesota roads.
The Crash Victims Memorial Wall project, developed by the Minnesota Department of Public Safety, reminds us that
traffic safety does matter. Driver and Vehicle Services driver’s license exam stations throughout Minnesota have
dedicated wall space for communities to commemorate crash victims.
To contribute a photograph to the Crash Victims Memorial Wall:
• Select a photograph (preferably with dimensions of 4" by 6" or 5" by 7") and place it in a simple frame of your
choice.
• If you wish, you may insert inside the frame a brief — neatly written or typed — statement about the person in the
photograph.
I hereby give the Minnesota Department of Public Safety the right to display the photographic image of
Name of Crash Victim (
)
PRINT OR TYPE
on its Crash Victims Memorial Wall. I certify that I have proper authority or permission to submit this photograph.
Your Relationship to the Person in the Photograph (
)
PRINT OR TYPE
I understand this image will be placed in public view and will be accessible to the public, including members of the media,
for viewing, photographing, and other reasonable uses.
I understand that the Department of Public Safety is not responsible for the loss of this photograph or for any damage
incurred to it. I understand that I may ask for its return at any time.
Yes
No
Would you like to indicate that the victim was killed by an alcohol-impaired driver?
Your Name
Street Address
City
State
Zip Code
Phone Number (
)
TYPE NO DASHES OR SPACES
Signature
Date
PS32005-01 (8/11)
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
Cra sh V ict i ms Me m o r i al Wa l l - P art i c ip ati on R ele ase
Please submit this signed release form, with photograph(s), to your local DVS exam station and/or to the Crash
Victims Memorial Wall in Saint Paul, MN. (Addresses on back.) Photographs may be displayed in one or both
locations.
Behaviors such as operating a motor vehicle while impaired by alcohol or drugs, traveling at unsafe speeds, and
engaging in aggressive and distracted driving cause hundreds of deaths and thousands of injuries annually on
Minnesota roads.
The Crash Victims Memorial Wall project, developed by the Minnesota Department of Public Safety, reminds us that
traffic safety does matter. Driver and Vehicle Services driver’s license exam stations throughout Minnesota have
dedicated wall space for communities to commemorate crash victims.
To contribute a photograph to the Crash Victims Memorial Wall:
• Select a photograph (preferably with dimensions of 4" by 6" or 5" by 7") and place it in a simple frame of your
choice.
• If you wish, you may insert inside the frame a brief — neatly written or typed — statement about the person in the
photograph.
I hereby give the Minnesota Department of Public Safety the right to display the photographic image of
Name of Crash Victim (
)
PRINT OR TYPE
on its Crash Victims Memorial Wall. I certify that I have proper authority or permission to submit this photograph.
Your Relationship to the Person in the Photograph (
)
PRINT OR TYPE
I understand this image will be placed in public view and will be accessible to the public, including members of the media,
for viewing, photographing, and other reasonable uses.
I understand that the Department of Public Safety is not responsible for the loss of this photograph or for any damage
incurred to it. I understand that I may ask for its return at any time.
Yes
No
Would you like to indicate that the victim was killed by an alcohol-impaired driver?
Your Name
Street Address
City
State
Zip Code
Phone Number (
)
TYPE NO DASHES OR SPACES
Signature
Date
PS32005-01 (8/11)
Cra sh V ict ims Mem o r i al Wa l l - L oc ati o ns a nd A d dr e s s e s
Mail or hand-deliver framed photographs and release forms to:
Driver’s License Exam Station
C/O Crash Victims Memorial Wall
Address
City, State ZIP code
Anoka
Mankato
530 West Main Street, Suite 5
2161 Bassett Drive
Anoka, Minnesota 55303
Mankato, Minnesota 56001
Arden Hills
Marshall
5400 Old Highway 8
601 D North Highway 59
35W and County Road I
Marshall, Minnesota 56258
Arden Hills, Minnesota 55112
Plymouth
Bemidji
2455 Fernbrook Lane
111 Second Street
Plymouth, Minnesota 55447
Union Square
Bemidji, Minnesota 56601
Rochester
1633 North Broadway
Brainerd
Rochester, Minnesota 55906
213 Fifth Street South
Brainerd, Minnesota 56401
St. Cloud
3333 W Division St - Suite 114
St. Cloud, Minnesota 56303
Detroit Lakes
1000 Highway 10 West
Department of Transportation Complex
St. Paul
Detroit Lakes, Minnesota 56501
445 Minnesota Street
Room 170
Duluth
St. Paul, Minnesota 55101
4602 Grand Avenue
Suite 990
Virginia
Duluth, Minnesota 55807
101 Hoover Road
Department of Transportation Building
Eagan
Virginia 55792
2070 Cliff Road
Eagan, Minnesota 55122
Willmar
1601 E Highway 12
Hastings
Willmar, Minnesota 56201
217 Ramsey Street
Hastings, Minnesota 55033
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