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This is a Ohio form that can be used for Miscellaneous within Statewide, Bureau Of Motor Vehicles.
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OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES NOTARIZED WRITTEN CONSENT RELEASE OF PERSONAL INFORMATION I, FULL NAME , SOCIAL SECURITY NUMBER authorize the Ohio Bureau of Motor Vehicles and all Clerk of Courts Title Offices to release my personal information, (name, address, date of birth, and driver license number) and all other information to . This authorization extends to records pertaining to my driver license, state identification card, vehicle registration, and Certificate of Title. This authorization extends to the release of medical and disability information. YES NO SIGNATURE DATE X Sworn to and subscribed in my presence by said Applicant on the day of , 20 . X NOTARY PUBLIC (Seal) My Commission expires: BMV 5008 6/14 [760-1491] American LegalNet, Inc. www.FormsWorkFlow.com