ࡱ> SURO =bjbjUU 47׎e7׎e D83tGGGGG"""$Gh"""""GGTTT"RGGT"TTTG.>tT0TRTT4""T"""""T"""""""""""""""" :  Any questions regarding the information on this form should be directed to University Police Department 361-593-2611 Type of Records This form authorizes the University Police Department to obtain a copy of the driving record containing the applicants name, date of birth, license status, and three years of records regarding accidents and/or moving violations. . Driver Record Check Requested By: Texas A&M UniversityKingsville University Police Department 700 University Blvd. , MSC 126 Kingsville, Texas 78363 Information Requested On: Texas Driver License Number: Date of Birth: Last Name: First Name: Middle Name: Phone Number: Department (if employed on campus): Other Names on Driver Record (e.g., Maiden Name): Individuals Written Consent For ONE TIME Release to Above Requestor I, ____________________________________________________, hereby certify that I granted access on this one occasion to my Driver License/ID Card record, inclusive of the personal information (name, address, driver identification number, etc.) to the Texas A&M University- Kingsville University Police Department. Signature of License/ID Card Holder or Parent/Legal Guardian Date State and Federal Law Requires Requestors to Agree to the Following: In requesting and using this information, I acknowledge that this disclosure is subject to the federal Drivers Privacy Protection Act (18 U.S.C. Section 2721 et seq.) and Texas Transportation Code Chapter 730. False statements or representations to obtain personal information pertaining to any individual from the DPS could result in the denial to release any driver record information to myself and the entity for which I made the request. Further, I understand that if I receive personal information as a result of this request, it may only be used to the stated purpose and I may only resell or redisclose the information pursuant to Texas Transportation Code 730.013. Violations of that section may result in a criminal charge with the possibility of a $25,000 fine. I certify that I have read and agree with the above conditions and that the information provided by me in this request is true and correct. If I am requesting this driver record on behalf of an entity, I also certify that I am authorized by that entity to make this request on their behalf. I also certify that I am authorized by that entity to make this request on their behalf. I also acknowledge that failure to abide by the provisions of this agreement and any state and federal privacy law can subject me to both criminal and civil penalties. _____________________________________________________ ________________________ Signature of Requestor (University Police) Date Revised 04/2018     APPLICATION FOR COPY OF TEXAS DRIVER RECORD Form 6  ~  + G K [ ] b c n q    2 : W & hKbhD[5hjjhjUhThTCJaJhTCJaJhEVhD[56CJaJhrnAhD[>*CJaJhD[>*CJaJhD[CJaJhEVhD[5CJaJhEVhD[CJaJhtCJaJ8~y   + c  W & -Q dgdT dgdD[dgdD[d&d P gdD[dgdt:;<= dgdD[gdTd&d P gdT#:;<=hThTCJaJhjhD[hKbhD[5 ht521h:pD[/ =!"#$% w666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666666866666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p(8HX`~8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666 OJPJQJ_HmH nH sH tH J`J  }fNormal dCJ_HaJmH sH tH DA D Default Paragraph FontRiR Table Normal4 l4a (k ( No List >@> D0HeaderdH$.. 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D0 Footer Charj3j T Table Grid7:V0PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] = % CCCCCF= = 8@0(  B S  ?    ; > iwJQ.1    ; > 333333  # > )1%D[ajTt @= (@UnknownG.[x Times New Roman5Symbol3. .[x Arial7..{$ CalibriC&,.{$ Calibri LightA$BCambria Math 1h1g1g)U U !24 .K#HP ?'D2 Farah C GuerraKirsten M Compary Oh+'0E  4 @ L Xdlt|Farah C GuerraNormalKirsten M Compary2Microsoft Office Word@@@>@>U GCVT$mZ !  !1.@"Calibri---  2 >`0   /2 >0 APPLICATION FOR COPY OF       2 >0 TEXAS   2 > 0 DRIVER RECORD      2 >40  e 2 >0 Form 6   2 >0    0''@"Calibri--- 2 l` 0   2 lxk0 Any questions regarding the information on this form should be directed to University Police Department 361     2 l0 - 2 l0 593  2 l0 - 2 l0 2611  2 l0   @"Calibri--- #2 `0 Type of Records   2 0    0- @ !t^- ''--- (2 `0 This form authorize   2 0 s  2 0   2 \0 the University Police Department to obtain a copy of the driving record containing the appli  2  0 cants name,    2 `k0 date of birth, license status, and three years of records regarding accidents and/or moving violations. .    2 Y0    =2 `!0 Driver Record Check Requested By:  2 0    0- @ !t^- '' )2 `0 Texas A&M University   2 0   2 0 Kingsville  2 0    72 `0 University Police Department    2 0    +2 `0 700 University Blvd.  2 0 ,  2 0 MSC 126   2 0    2 `0 Kingsvil "2 0 le, Texas 78363  2 0     2 +`0   --- 12 9`0 Information Requested On:   2 90    0- @ !t>^- ''--- 52 Z`0 Texas Driver License Number:   2 Z0  -  2 Z 0  0  2 ZP0  0  2 Z0  0 2 Z0    2 Z0 Date of Birth: 2 Z0    2 Z0    2 Z0  0  2 Z@0  0  2 Zp0  0  2 Z0  0  2 Z0  @ Calibri---- @ ![-- @ ![- --- 2 v` 0 Last Name:    2 v0  %  2 v0  0  2 v0  0 2 v 0   2 v+ 0 First Name:   2 vf0    2 v0  0  2 v0  0 2 v0   2 v 0 Middle Name:    2 v.0    2 v@0  0  2 vp0  0  2 v0  0 2 v0    2 v0  - @ !w-- @ !zwf-- @ !w.- ---  2 `0 Phone Number:    2 0    2 0  0  2 0  0 2  0    2 %0  + A2 P$0 Department (if employed on campus):      2 0    2 0  0  2 @0  0  2 p0  0  2 0  0  2 0  - @ !n-- @ !- --- J2 `*0 Other Names on Driver Record (e.g., Maiden    2 <0   2 >0 Name):    2 e0    2 0  0  2 0  0  2 0  0  2 0  0  2 @0  0  2 p0  0  2 0  0  2 0  - @ !ke- ---@"Calibri------------ =2 `!0 Individuals Written Consent For  --- 2 0 ONE TIME ---  2 50   42 90 Release to Above Requestor   2 0    0- @ !t^- ''--- 2 `v0 I, ____________________________________________________, hereby certify that I granted access on this one occasion to   X2 `30 my Driver License/ID Card record, inclusive of the  }2 VL0 personal information (name, address, driver identification number, etc.) to      /2 `0 the Texas A&M University   2 0 -  2 0   G2 (0 Kingsville University Police Department.   2 0     2 "`0  0  2 "0  0  2 "0  0  2 "0  0  2 " 0  0  2 "P0  0  2 "0  0  2 "0  0  2 "0  0  2 "0  0  2 "@0  0  2 "p0  0  2 "0  0  2 "0  - @ !#`-- @ !#- --- e2 >`<0 Signature of License/ID Card Holder or Parent/Legal Guardian  2 >0  !  2 >0  0  2 >0  0 2 >0 Date  2 >*0   --- :2 Y`0 State and Federal Law Requires   C2 Y%0 Requestors to Agree to the Following:   2 Y0    0- @ !t^^- ''--- 2 y`}0 In requesting and using this information, I acknowledge that this disclosure is subject to the federal Drivers Privacy Prote   2 y0 ction   2 `W0 Act (18 U.S.C. Section 2721 et seq.) and Texas Transportation Code Chapter 730. False s F2  '0 tatements or representations to obtain    2 `w0 personal information pertaining to any individual from the DPS could result in the denial to release any driver record     2 `b0 information to myself and the entity for which I made the request. Further, I understand that if I      2 80   72 :0 receive personal information    2 `{0 as a result of this request, it may only be used to the stated purpose and I may only resell or redisclose the information      2 `g0 pursuant to Texas Transportation Code 730.013. Violations of that section may result in a criminal cha   12 Y0 rge with the possibility    (2 `0 of a $25,000 fine.   2 0    2 `}0 I certify that I have read and agree with the above conditions and that the information provided by me in this request is tru    2 0 e   2 `T0 and correct. If I am requesting this driver record on behalf of an entity, I also ce  V2 20 rtify that I am authorized by that entity to make     2 `}0 this request on their behalf. I also certify that I am authorized by that entity to make this request on their behalf. I also    2 0    2 `P0 acknowledge that failure to abide by the provisions of this agreement and any st  P2 .0 ate and federal privacy law can subject me to     >2 (`"0 both criminal and civil penalties.   2 (0    _2 D`80 _____________________________________________________   2 D0    2 D0  0  2 D0  0 /2 D0 ________________________  2 D0     2 R`0   J2 R*0 Signature of Requestor (University Police)  2 RT0  ,  2 R0  0  2 R0  0  2 R0  0  2 R0  0 2 R@0 Date  2 RZ0    0- @ !t_^- ''  2 m`0    "2 `0 Revised 04/2018  2 0   "System0 0 --  00//..? ՜.+,0 hp  $Texas A&M University--Kingsville   Title  !"#$%&()*+,-./0123456789:;<=>?@ABCDEFGHIKLMNOPQTRoot Entry FS1>VData 1TableWordDocument4SummaryInformation('EDocumentSummaryInformation8JCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q