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The form instructs applicants that multiple requests must be sent together with the Driving Record Search form and explains that applicable fees should be consulted. It collects applicant and licence-holder identity details, driver’s licence number, birth date, and contact information, and grants disclosure of suspensions, revocations, demerit points, offences, and relevant heavy-vehicle accidents for twelve months.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/authorization-for-the-disclosure-of-a-driving-record-notice-to-the-applicant/307831/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/authorization-for-the-disclosure-of-a-driving-record-notice-to-the-applicant/307831.png","ImageObject",300,407,{"name":92,"@type":93},"Quinn Holloway","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is authorized on the driving record disclosure form?","Question",{"text":112,"@type":113},"The licence holder authorizes the Société de l’assurance automobile du Québec to disclose the content of the driving record, including suspensions, revocations, demerit points, offences, and relevant accidents while driving a heavy vehicle, if applicable, to the named applicant.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How long is the authorization valid?",{"text":117,"@type":113},"The authorization is valid for twelve (12) months from the date of signature.",{"name":119,"@type":110,"acceptedAnswer":120},"What happens if the applicant does not provide required personal information?",{"text":121,"@type":113},"Failure to provide information can result in refusal of service by the Société.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},307831,1789985158,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81},2336474466712,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Authorization for the Disclosure of a Driving Record by the Société de l’assurance automobile du Québec  \nNotice to the applicant  \nWhen more than one request is to be submitted to the SAAQ, they must be sent together with the form entitled Driving Record Search (4941A) . Consult the fees required for each record.  \n\n| INFORMATION ON THE APPLICANT |  |\n| --- | --- |\n| Company, agency or other (in block letters)\u003Cbr>Applicant Insight Ltd, Inc |  |\n| Last name and first name of the person authorized to act on behalf of the applicant (in block letters) |  |\n| Address (Number, street, apt.)\u003Cbr>Po Box 458 |  |\n| Municipality/Province Postal code\u003Cbr>\u003Cbr>New Port Richey, FL 34656 | Telephone Ext.\u003Cbr>\u003Cbr>800 245-2318\u003Cbr>2118 |\n\n\n| AUTHORIZATION OF THE LICENCE HOLDER |\n| --- |\n| Driver’s licence number\u003Cbr>Fill all 13 spaces |\n| \u003Cbr>Last name and first name of driver’s licence holder |\n| |\n| Date of birth Year\u003Cbr>Month\u003Cbr>Day\u003Cbr>Telephone (home)\u003Cbr>Telephone (work) extension |\n| I, the undersigned, authorize the Société de l’assurance automobile du Québec to disclose the content of my driving record, in particular, suspensions, revocations, demerit points, offences, as well as accidents in which I was involved while driving a heavy vehicle, if applicable, to the above-named applicant. This authorization is valid for twelve (12) months as of the date of signature.\u003Cbr>Year-Month-Day |\n| Date Signature of licence holder |\n\nProtection of Personal Information  \nAll information gathered by authorized Société de l’assurance automobile du Québec personnel is handled confidentially. The Société requires this personal information to apply the Automobile Insurance Act and the Highway Safety Code. Under the Act respecting access to documents held by public bodies and the Protection of personal information, it may be conveyed to Government departments or agencies, or used for statistical, survey, study, audit or investigative purposes. Failure to provide information can result in a refusal of service on the Société’s part. Individuals may consult or correct any personal information concerning them held in Société records.  \nFor more information, consult the Policy on Privacy on the Société’s Web site at: [www.saaq.gouv.qc.ca](www.saaq.gouv.qc.ca) or contact the Société’s call centre.  \n• For any information, call 418 528-3183 toll-free 1 866 642-1865  \n• Fax 418 644-7167  \n• All applications must be sent to:  \nService de la diffusion et de la liaison avec les corps policiers  \nSociété de l’assurance automobile du Québec  \n333, boulevard Jean-Lesage, C-3-44  \nCase Postale 19600, succursale Terminus Québec (Québec) G1K 8J6  \nSociété de l’assurance automobile du Québec  \n5981A 50 (2012-01)","cbCaivW0PwdAUwLE","https://ap.wps.com/l/cbCaivW0PwdAUwLE","pdf",179699,"English","# Notice to the applicant\n## Instructions for submitting requests\n# Information on the applicant\n# Authorization of the licence holder\n## Validity period and scope of disclosure\n# Protection of Personal Information","[{\"question\":\"What is authorized on the driving record disclosure form?\",\"answer\":\"The licence holder authorizes the Société de l’assurance automobile du Québec to disclose the content of the driving record, including suspensions, revocations, demerit points, offences, and relevant accidents while driving a heavy vehicle, if applicable, to the named applicant.\"},{\"question\":\"How long is the authorization valid?\",\"answer\":\"The authorization is valid for twelve (12) months from the date of signature.\"},{\"question\":\"What happens if the applicant does not provide required personal information?\",\"answer\":\"Failure to provide information can result in refusal of service by the Société.\"}]","Authorization for the Disclosure of a Driving Record - Notice to the Applicant | PDF",1789855980]