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Consult the fees required for each record.  \n\n| INFORMATION ON THE APPLICANT |  |\n| --- | --- |\n| Company, agency or other (in block letters) |  |\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.) |  |\n| Municipality/Province Postal code\u003Cbr>| Telephone Ext.\u003Cbr>|\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)","cbCaikEbloEijMDl","https://ap.wps.com/l/cbCaikEbloEijMDl","pdf",201179,"English","# Notice to the applicant\n## Authorization of the licence holder\n# Protection of Personal Information","[{\"question\":\"Who can request disclosure of driving record information from SAAQ?\",\"answer\":\"The form authorizes the Société de l’assurance automobile du Québec to disclose the licence holder’s driving record contents to the above-named applicant.\"},{\"question\":\"How long is the authorization valid?\",\"answer\":\"The authorization is valid for twelve (12) months as of the date of signature.\"},{\"question\":\"What happens if required personal information is not provided?\",\"answer\":\"Failure to provide information can result in a refusal of service on the Société’s part. Individuals may consult or correct personal information held in SAAQ records.\"}]","Authorization for the Disclosure of a Driving Record | PDF",1789856899]