DMV REQUEST FORM FOR IGNITION INTERLOCK DOCUMENTS

NC DMV
DIVISION OF HEARINGS
REQUEST FORM FOR IGNITION INTERLOCK DOCUMENTS
Ignition Interlock documents may be obtained from the ignition interlock provider once permission is
given by the NC Division of Motor Vehicles.
I am requesting ignition interlock reports for the following person(s):
NCDL/ID #_______________ Name _______________________ DOB_________________
NCDL/ID #_______________ Name _______________________ DOB_________________
Please circle the number below that best describes the reason the information is being requested:
1. For the driver’s own personal record.
2. For use by any government agency in carrying out its function, or for use by any private
person or entity action on behalf of a government agency. (List agency name:
___________________________________)
3. For use in connection with any civil, criminal, administrative or arbitration proceeding in any
federal, state or local court or agency.
4. For use by private investigators or licensed security service for any purposes listed herein. NC
Private Investigator License # _____________________________.
5. For use by any requestor who has obtained written consent of the individual to whom the
information pertains. Attach a copy of the written consent.
I am qualified to receive this information under the category circled above. I understand that I may not
re-disclose this information except for the reason listed above.
Requested by: Full Name (print)________________________________ Date______________
Signature (Required) __________________________________________________________
Mailing Address ______________________________________________________________
State ______________ Zip Code __________________