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Driver Experience Certificate

The document is a request form for a Manitoba Driver Experience Letter. It collects the requester's name, date of birth, driver's license number, approximate year of last valid Manitoba license, contact information, and mailing or fax information for where to send the letter. It also collects payment information of either a credit card or cheque/money order for the $10 fee.

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rohitgawai99
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799 views1 page

Driver Experience Certificate

The document is a request form for a Manitoba Driver Experience Letter. It collects the requester's name, date of birth, driver's license number, approximate year of last valid Manitoba license, contact information, and mailing or fax information for where to send the letter. It also collects payment information of either a credit card or cheque/money order for the $10 fee.

Uploaded by

rohitgawai99
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Driver Experience Letter Request Form

I, ___________________________________, authorize Manitoba Public Insurance to process my Manitoba


(Print Name)

Driver Experience Letter which will include the past 10 years of my driving history.

My full name is: _________________________________________. Previous Name: __________________________.


(First/Middle/Last) (If Changed)

My date of birth is: _______________________________________.


(MMM/DD/YYYY)

My Manitoba driver’s licence number is: _____________________________________.


(If Available)

Approximate year I last held a valid Manitoba driver’s licence: ______________________________.

Telephone Number: ( ) __________________________________.

I authorize Manitoba Public Insurance to MAIL my Driver Experience Letter to the following address or FAX my
Driver Experience Letter to the following:

Mailing Address: ____________________________________ OR Fax Number: ____________________________

____________________________________

____________________________________

_______________________________________________________ _______________________________________
Signature of Driver Date Signed

Please charge the $10.00 fee (per letter) to my VISA / MASTERCARD indicated below. (Circle one)

My credit card number is: _________________________

My credit card expiry is: _________________________

Signature of Card Holder: _________________________


OR
I will be mailing in a cheque or money order (made payable to Manitoba Public Insurance)

Please note this fee is non-refundable.

Mail/Fax Request To: OFFICE USE


Manitoba Public Insurance ONLY:
Driver Licence Processing Fee Paid
Box 6300
Winnipeg, MB R3C 4A4 $10
Fax: 204-953-4999

FOR MORE INFORMATION CALL: 204-985-8770 ext.1646 or TOLL FREE: 1-800-665-2410

**PLEASE ALLOW 5 BUSINESS DAYS FOR PROCESSING**

Rev 05/15

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