2. Date:
   Date:
4. First Name
5. Middle Name
6. Last Name
8. D.O.B.
   D.O.B.
9. Driver's License Number
10. State
14. Person Making Request
16. Fire Department
20. Return Date:
22. Driving Record Results:
23. Acceptable:
24. Not Acceptable
28. Criminal History Results:
29. No History
30. Prior History
34. Any questions contact Lt. Perdue at 517-264-5373
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field