Secure Client Information Form

Please complete this Secure and Confidential Client Information Form so that I have the information necessary to obtain your Massachusetts Driving Record and file any necessary paperwork on your behalf. This is a secure web form and the information you provide will be kept confidential.

Client Information Form

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Name

First

Last

Street Address

Address Line 2

City

Country

Phone *

Email *

Location of your most recent violation / court appearance (City / State) *

Massachusetts License Number, ID Card Number, or Customer ID

I must have your Massachusetts License Number or Customer ID Number to obtain your Massachusetts Driving Record.

Date of Birth *

Social Security Number

The Registry Requires this to obtain your Driving Record and the Board of Appeal requires this for the filing of any appeal.

Brief Description of your Situation

File Upload

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