PA ON-LINE REGISTRATON PROGRAM

AUTHORIZATION FOR INQUIRY

OF MOTOR VEHICLE RECORD

The Pennsylvania Department of Transportation collects confidential and personal

information from the public to administer the various PA On-Line Registration Programs
(PA OLRP) for which it has responsibility. PennDOT takes this responsibility of keeping
our customers information confidential very seriously. As a requirement of the PA OLRP
to obtain any owner and/or vehicle information needed to assist in a transaction of a
vehicle purchase, the customers signature of authorization is required.
* * * * NOTICE * * * *
THIS FORM MUST BE MAINTAINED IN THE OFFICE OF THE
REQUESTER FOR A PERIOD OF 3 YEARS AND IS SUBJECT TO
A BUSINESS PARTNER AND/OR DEPARTMENTAL AUDIT
WITHOUT PRIOR NOTIFICATION.
Complete ALL Information Requested. Please print clearly
A OWNER INFORMATION
Name(s):
Street Address:
City:
B TYPE OF INQUIRY BEING PROCESSED

State:

Zip:

Vehicle Identification Number:

Title Number:
License Plate Number:

C REASON FOR INQUIRY

Please provide a brief description concerning the type of information needed to assist in the transaction.

X________________________ X_______________________ X___________________

Vehicle Owner/Lessee Signature

Vehicle Co-Owners Signature

Date

X________________________X________________________ X___________________
Signature of Person processing Inquiry

Position Title

Date