puerto rico specific information

Please be advised that when requesting records from Puerto Rico for insurance and
employment purposes, the end-user is required to have a release form signed by the
prospective applicant/employee. This release form must be faxed to Softech at 1-305-6476504.
PUERTO RICO SPECIFIC INFORMATION:
1. Client Information
 Softech Account Number
2. Application/Subject Information
Last Name, First Name, MI (If driver has more than one last name please list all.)
 Driver’s License Number
 Date of Birth
 Social Security Number

3. Driver Authorization
 Driver’s Signature and Date (Please have applicant/employee sign and date.)
IMPORTANT:

The Puerto Rico Release form:
1. Must be completed and faxed to Softech at 1-305-647-6504 in order for the request to be filled.
2. DO NOT SEND A FAX COVER SHEET
3. Must be completed as directed and the original kept on file by the end-user/employer.
Created 1/09
PR Release Instructions
Rev. 8/15
Softech Account# _______________
Puerto Rico Authorization for
Release of Driving Record (Legitimate Business Purpose)
I, ______________________________________ do hereby authorize and allow Success In Action, Inc., as
agent for Softech International Inc to obtain a copy of my driver’s license abstract information which will
be used for verification of information for a legitimate business purposes.
La Autorización de Puerto Rico para la Liberación del Registro Impulsor
(Proposito Legitimo de Negocio)
Yo, _____________________________________ por la presente autorizo y doy permiso a Success In
Action, Inc., como agente de Softech International Inc a obtener una copia de la información abstracta
de mi licencia de conducir, la cual será utilizada para comprobar que la información obtenida es por un
propósito legítimo de la Compañía.
_____________________________________________________________________________________
Full Name (please print)/Nombre Completo (letra de molde)
_____________________________________________________________________________________
License Number/Numero de Licencia de Conducir
Date of Birth/Fecha de Nacimiento: ___________________
Social Security Number/Numero de Seguro Social: ____________________________________________
Reference: ____________________________________________________________________________
_____________________________________________________________________________________
Signature/Firma
Date/Fecha