3A. CERTIFIED version Driver Record. Acceptable for DDC Course

Please fill out the registration form completely. Asterisk (*) indicate required fields

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*Driver License Number:
*Date of Birth (mm/dd/yyyy):	(month) JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC   (day) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
*Last Four Digits of Social Security #:
*DPS Audit Number:

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*First Name:
*Last Name:
*Mailing Address:
*City:
*State:	(Select State) AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
*Zip Code:	-

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I, the licensee, hereby certify that I grant access on this one occasion to my Driver License/ID Card record, inclusive of the personal information (name, address, driver identification number, etc. ), to DefensiveDriving.com.

All driver records are processed at the time your order is placed. We are unable to issue refunds for driver record requests.