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2. SECTION I. REQUESTER INFORMATION:
4. Full Name:
6. Firm/Corporation:
8. Phone Number:
10. Street Address:
12. Date of Request:
16. SECTION II: RECORD INFORMATION REQUEST
18. Date of Incident:
20. Glendale Case Number:
22. Location of Incident:
24. Incident Description:
26. Party Name to the Incident:
30. SECTION III: AUTHORIZATION
    I/We do hereby certify that we are authorized under the Federal Driver's Privacy Protection Act to obtain the identified report and personal information based upon the following:
32. 1. 1. Authorized for use, if Requester has obtained the written consent from the person about whom the information pertains. (If you choose this option, please also select an option to the right)
33. 1. I am requesting a copy of my own record.
    2. I am a parent or legal guardian of a minor child and I am requesting a copy of his/her record.
    3. I am requesting a record of another person and have attached their written consent.
35. Attached Written Consent (Per option 3)
37. 1. 2. For use in connection with matters of a motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls or advisories; performance monitoring of motor
39. 1. 3. A government agency (Federal, State, local or tribal) or employed by such, for the purposes of the government agency to carry out its official functions.
41. 1. 4. A Federal, State, Circuit, local or tribal court, or employed by such, for the purposes of the court to carry out its official functions.
43. 1. 5. A Wisconsin or out-of-state law enforcement agency, or such a person employed by such, for the purposes of the law enforcement agency to carry out its official functions.
45. 1. 6. Authorized representative, agent, contractor, or employed by such, of a legitimate business, but only to (a) verify accuracy of the personal information; (b) obtain correct information, but only fo
47. The Driver's Privacy Protextion Act is enforced by the United States Department of Justice, which may seek civil and criminal penalties for improperly obtaining, disclosing or using personal information from an accident report or other record, or the information was acquired through the T.I.M.E System and it is determined that these records are used for purpose other than as stated in this Request. In such instances, penalties may be imposed pursuant to Title 18 USC, Section 2724 of the United States Code.
49. Electronic Signature:
50. Date:
54. Departmental Use Only
56. Date Received:
58. Case Number:
60. Forward all requests to Captain's Office.
62. Final Approval
63. Date:
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

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