California Request Application
A Public Service Agency INFORMATION SERVICES BRANCH
COMMERCIAL REQUESTER ACCOUNT APPLICATION
The Department of Motor Vehicles (DMV) is authorized by California Vehicle Code (CVC) Section 1810.2 to establish Commercial Requester Accounts and issue requester codes for the purpose of obtaining information from the DMV files. Commercial Requester Accounts are established for applicants that: (1) have a legitimate business need for the information; (2) submit completed application forms; and (3) pay the required application fee.
There are three types of Commercial Requester Accounts. Each is identified and described below with the list of forms to be completed. A separate application, agreement, and fee required for each type. Send the required forms and fees to:
Department of Motor Vehicles Questions? Call (916) 657-5564
Accounts Processing – H221
PO Box 944231
Sacramento, CA 94244-2310
*NOTE: $50 OF THE APPLICATION FEE WILL BE RETAINED BY DMV TO COVER PROCESSING COSTS.
Confidential Residence Address: Residence address information is confidential and will not be released unless authorized under statutory authority by a state or federal statute that specifies and requires DMV to release the information.
← End User – Requesters who receive information for an authorized business use.
2 INF 1106E Application Commercial Requester Account (End User) *Fee: $50 (no residence address) OR
2 INF 1108 Commercial Requester Account Agreement $250 (for residence address) AND
1 INF 1132 Information Services Surety Bond (DO NOT COMPLETE $50,000 Surety Bond
UNTIL APPROVED FOR RESIDENCE ADDRESS)
← Vendor – A person who has been approved by the department to directly receive and transmit information, according to DMV requirements, to another authorized intermediate vendor and/or authorized end user. Information received from DMV shall not be retained or combined with any other data on any database for any reason without prior written approval from the department. A Vendor cannot use the information for their own purpose.
Intermediate Vendor-A person who has been approved by the department to directly receive and transmit information, from an End User through another authorized vendor according to DMV requirements. Information received from DMV shall not be retained or combined with any other data on any database for any reason without prior written approval from the department. An Intermediate Vendor cannot use the information for their own purpose.
2 INF 1106V Application Commercial Requester Account (Vendor) *Fee: $250 application fee
2 INF 1108 Commercial Requester Account Agreement $50,000 Surety Bond (for
1 INF 1132 Information Services Surety Bond (DO NOT COMPLETE residence address)
UNTIL APPROVED FOR RESIDENCE ADDRESS)
← Agent: A person who has been authorized by an End User requester account holder to receive record information directly from the department to perform a specific business function.
2 INF 1106A Application Commercial Requester Account (Agent) *Fee: $250 application fee
2 INF 1108 Commercial Requester Account Agreement $50,000 Surety Bond (for
2 INF 02 Agent Addendum residence address)
2 INF 03 Agent Authorization
1 INF 1132 Information Services Surety Bond (DO NOT COMPLETE
UNTIL APPROVED FOR RESIDENCE ADDRESS)
Additional Forms-All of the following forms may be duplicated or contact Account Processing if needed.
2 INF 1110 Representative Non-Disclosure Statement is to be completed when an individual, other than an employee, is authorized by a requester account holder to perform a specified business function. The representative may not directly request or receive information from DMV. Process Servers may not use an INF 1110 unless the information was obtained pursuant to California Vehicle Code Sections 1808.22 or 1808.23. This form is to be retained at the worksite.
2 INF 1128 Employee Security Statement is to be completed by your employee(s) who are responsible for handling information received from the department. This form is to be retained at the worksite.
1 INF 1213 Commercial Requester Account Notice of Change is to be completed when there is a change in the corporate name only, corporate officers only, sole proprietor, DBA, telephone number, account contact/telephone number, street, mailing, or record storage address, billing contact, address and telephone number. In addition, complete this form when requesting a change in the proposed use of your account. (Retain for Future use.)
1 INF 1184 Certification of Agency is to be completed by any Registration Service who will be requesting residence address information in order to process vehicle registration transactions/documents on behalf of a vehicle dealer. (Contact Account Processing at (916) 657-5564 to obtain a copy of this form.)
1 INF 1106BL Requester Code Branch Locations is to be completed if each branch location is to have their own
requester code. (Contact Account Processing at (916) 657-5564 to obtain a copy of this form.)
A Public Service Agency APPLICATION
COMMERCIAL REQUESTER ACCOUNT
(END USER)
Please print clearly or type
Check one: ( Sole Ownership ( Partnership ( Corporation
| |DMV USE ONLY |
|PART A: Main Office |Requester Code |
|NAME OF INDIVIDUAL, PARTNERSHIP, OR CORPORATION |TELEPHONE NUMBER | |
| | | |
| |( ) Ext. | |
|FIRM OR TRADE NAME |DBA | |
|ACCOUNT CONTACT PERSON |TELEPHONE NUMBER | |
| | | |
| |( ) Ext. | |
| | |
|STREET ADDRESS (PHYSICAL LOCATION) CITY STATE | |
|ZIP CODE | |
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
RECORD STORAGE ADDRESS (PHYSICAL LOCATION WHERE RECORDS WILL BE MAINTAINED FOR ON-SITE INSPECTION. REVIEW OR AUDIT BY DMV OR ITS REPRESENTATIVES)
(IF SAME, AS ABOVE, SO STATE CITY STATE ZIP CODE
PART B: Ownership
Instructions: List name, title and driver license/identification card number (DL/ID) and the state issued of individual (sole owner), each partner and each corporate officer participating in the direction, control or management of the business.
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
PART C: Licensing and Business Identification
Instructions: Please provide your federal employer identification, corporation number and state in which issued. If your business is required to be licensed by any local, state, or federal government entity (Motor Vehicles Insurance, Consumer Affairs, etc.,) or you are a state bar member, please provide the licensing information as indicated and attach a copy of the license for verification purposes.
|Federal Employer ID No. |Corporation No./State Issued |License Type |Agency Issuing License |License No. and Expiration Date |
| | | | | |
| | | | | |
PART D: Commercial Requester Account History and Use
Instructions: Answer each question. If additional space is needed attach a separate sheet with name and address as shown above.
1. Have you, your partners, any corporate officer, or the business previously applied for, had, or have a Commercial Requester Account?
( Yes ( No If yes, enter the current/prior Agreement number/requester code(s) below.
Agreement Number __________________________ Requester Codes ______________________________________________
2. Have you, your partners, any corporate officer, or the business been subject to a Department of Motor Vehicle administrative action
against a prior or current Commercial Requester Account. ( Yes ( No If yes, identify the type of action, the name of the person
and/or business and the reason in the space provided.
__________________________________________________________________________________________________________
3. Have you, your partners, any corporate officer ever been convicted of any crime for a violent act, stalking, computer fraud, unauthorized
disclosure, access or distribution of information. ( Yes ( No If yes, identify the name of the person, the violation, and the
action taken below.
__________________________________________________________________________________________________________
4. Do you intend to sell the information to another entity? (Commercial Requester Account End Users/Agents are prohibited from reselling
information to another entity. Accounts established for this purpose are defined as Vendors. Vendors may resell information only to
approved Commercial Requester Account End Users and cannot request information for their own purpose.) (Yes ( No
5. Do you intend to provide a business function to a government agency and/or employer enrolled in the Employer Pull Notice Program
based on the information purchased from the department? (Yes ( No If yes, accounts established for this purpose are defined
as Government and/or Employer Pull Notice (EPN) Agents. A separate Government Agent or EPN Agent application is required.
PART E: Billing Contact and Address
Instructions: If purchasing information directly from the department, identify the name and telephone of the person to contact for information concerning billing and the billing address. (If same as account contact listed in Section A, so state.)
BILLING CONTACT NAME (FIRST, MI, LAST) TELEPHONE NUMBER
( ) Ext.
MAILING ADDRESS CITY STATE ZIP CODE
PART F: Requester Information
Instructions: Check the box(es) that best identifies the occupation (trade, profession, or business type) for the account.
( Attorney ( Dismantler ( Insurance Company ( Manufacturer ( Process Server
( Auto Dealer ( Financial Institution ( Lessor-Retailer ( Media ( Registration Service
( Auto Auction ( Insurance Agent/Broker ( Lien Sale ( Private Investigator ( Salvage Pool
( Other ______________________________________________________________________________________________________
PART G: Account Purposes, Type of Records and Address Access
Instructions: Complete a separate section for each purpose and explain how the information received will be used under proposed use, select the types of records requested. Check either “yes” or “no” for confidential residence address information. If yes, the Commercial Requester Account Agreement requires the specific regulation, rule of court, federal, or state statute identified by code name and section number which authorizes the use of Department of Motor Vehicle residence address information.
Type Record Abbreviations Guide
DL/ID-Driver License/Identification Card VR-Vehicle/Vessel Registration FR-Financial Responsibility OL-Occupational Licensee
1. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
2. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
3. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
4. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
PART H: Statement of Understanding, Certification Signature(s)
Instructions: Please read the statement of understanding, complete the “Executed at” line and sign A, B, or C, as appropriate.
I understand that false or misleading answers are cause for denial of an application and/or termination of any access agreement granted. I authorize the Director of the Department of Motor Vehicles, or the Director’s designee, to investigate any matter or statements contained in this application.
I understand that if this Application for a Commercial Requester Account is approved, I will be required to conform to the statements presented within. I further understand that I will be required to sign an agreement which will become part of this application. This application and the agreement specify the terms and conditions of our relationship. Any deviations will be considered by the Department of Motor Vehicles as misuse, and may result in both revocation of the account and refusal of subsequent applications.
I understand that according to provisions of the California Vehicle Code Section 1808.45, the willful, unauthorized disclosure of information from any department record for a purpose other than the one stated in the request or the sale or other distribution of the information to a person or organization not disclosed in the request is a misdemeanor, punishable by a fine not exceeding $5,000 or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment.
I understand that according to provisions of the California Vehicle Code Section 1808.46, any person holding a requester code who directly or indirectly obtains information from the Department of Motor Vehicles using false representations or distributes restricted or confidential information to any person or uses the information for a reason not authorized or specified in this application is liable to the Department of Motor Vehicles for civil penalties up to $100,000 and shall have their requester code privileges suspended for a period of up to five (5) years or revoked.
EXECUTED AT (CITY) (COUNTY) ON (DATE)
A. Individual: I certify under the penalty of perjury that I am the sole owner as shown on this application, and that no other person is
associated in the ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE
X
B. Partnership: We certify under the penalty of perjury that we are co-partners as shown on this application and that no other person is
associated in the ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE SIGNATURE
X X
C. Corporation:I certify under the penalty of perjury that I am a corporate officer authorized to sign for the corporation identification number
and the state shown on this application are valid and that all answers and information contained within this application are true & correct
SIGNATURE OF CORPORATE OFFICER AUTHORIZED TO SIGN FOR CORPORATION TITLE
X X
___________________________________________________________________________________________________________________________________________________________________
NOTE: Branch locations may be assigned separate requester codes by completing the form Requester Codes for Branch
Locations (INF 1106BL). A Separate application is required for any location operating under a different ownership.
A Public Service Agency APPLICATION
COMMERCIAL REQUESTER ACCOUNT
(END USER)
Please print clearly or type
Check one: ( Sole Ownership ( Partnership ( Corporation
| |DMV USE ONLY |
|PART A: Main Office |Requester Code |
|NAME OF INDIVIDUAL, PARTNERSHIP, OR CORPORATION |TELEPHONE NUMBER | |
| | | |
| |( ) Ext. | |
|FIRM OR TRADE NAME |DBA | |
|ACCOUNT CONTACT PERSON |TELEPHONE NUMBER | |
| | | |
| |( ) Ext. | |
| | |
|STREET ADDRESS (PHYSICAL LOCATION) CITY STATE | |
|ZIP CODE | |
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
RECORD STORAGE ADDRESS (PHYSICAL LOCATION WHERE RECORDS WILL BE MAINTAINED FOR ON-SITE INSPECTION. REVIEW OR AUDIT BY DMV OR ITS REPRESENTATIVES)
(IF SAME, AS ABOVE, SO STATE CITY STATE ZIP CODE
PART B: Ownership
Instructions: List name, title and driver license/identification card number (DL/ID) and the state issued of individual (sole owner), each partner and each corporate officer participating in the direction, control or management of the business.
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
PART C: Licensing and Business Identification
Instructions: Please provide your federal employer identification, corporation number and state in which issued. If your business is required to be licensed by any local, state, or federal government entity (Motor Vehicles Insurance, Consumer Affairs, etc.,) or you are a state bar member, please provide the licensing information as indicated and attach a copy of the license for verification purposes.
|Federal Employer ID No. |Corporation No./State Issued |License Type |Agency Issuing License |License No. and Expiration Date |
| | | | | |
| | | | | |
PART D: Commercial Requester Account History and Use
Instructions: Answer each question. If additional space is needed attach a separate sheet with name and address as shown above.
1. Have you, your partners, any corporate officer, or the business previously applied for, had, or have a Commercial Requester Account?
( Yes ( No If yes, enter the current/prior Agreement number/requester code(s) below.
Agreement Number __________________________ Requester Codes ______________________________________________
2. Have you, your partners, any corporate officer, or the business been subject to a Department of Motor Vehicle administrative action
against a prior or current Commercial Requester Account. ( Yes ( No If yes, identify the type of action, the name of the person
and/or business and the reason in the space provided.
__________________________________________________________________________________________________________
3. Have you, your partners, any corporate officer ever been convicted of any crime for a violent act, stalking, computer fraud, unauthorized
disclosure, access or distribution of information. ( Yes ( No If yes, identify the name of the person, the violation, and the
action taken below.
__________________________________________________________________________________________________________
4. Do you intend to sell the information to another entity? (Commercial Requester Account End Users/Agents are prohibited from reselling
information to another entity. Accounts established for this purpose are defined as Vendors. Vendors may resell information only to
approved Commercial Requester Account End Users and cannot request information for their own purpose.) (Yes ( No
5. Do you intend to provide a business function to a government agency and/or employer enrolled in the Employer Pull Notice Program
based on the information purchased from the department? (Yes ( No If yes, accounts established for this purpose are defined
as Government and/or Employer Pull Notice (EPN) Agents. A separate Government Agent or EPN Agent application is required.
PART E: Billing Contact and Address
Instructions: If purchasing information directly from the department, identify the name and telephone of the person to contact for information concerning billing and the billing address. (If same as account contact listed in Section A, so state.)
BILLING CONTACT NAME (FIRST, MI, LAST) TELEPHONE NUMBER
( ) Ext.
MAILING ADDRESS CITY STATE ZIP CODE
PART F: Requester Information
Instructions: Check the box(es) that best identifies the occupation (trade, profession, or business type) for the account.
( Attorney ( Dismantler ( Insurance Company ( Manufacturer ( Process Server
( Auto Dealer ( Financial Institution ( Lessor-Retailer ( Media ( Registration Service
( Auto Auction ( Insurance Agent/Broker ( Lien Sale ( Private Investigator ( Salvage Pool
( Other ______________________________________________________________________________________________________
PART G: Account Purposes, Type of Records and Address Access
Instructions: Complete a separate section for each purpose and explain how the information received will be used under proposed use, select the types of records requested. Check either “yes” or “no” for confidential residence address information. If yes, the Commercial Requester Account Agreement requires the specific regulation, rule of court, federal, or state statute identified by code name and section number which authorizes the use of Department of Motor Vehicle residence address information.
Type Record Abbreviations Guide
DL/ID-Driver License/Identification Card VR-Vehicle/Vessel Registration FR-Financial Responsibility OL-Occupational Licensee
1. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
2. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
3. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
4. Identify Proposed Use: __________________________________________________________________
_________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR Residence Address: ( Yes ( No
PART H: Statement of Understanding, Certification Signature(s)
Instructions: Please read the statement of understanding, complete the “Executed at” line and sign A, B, or C, as appropriate.
I understand that false or misleading answers are cause for denial of an application and/or termination of any access agreement granted. I authorize the Director of the Department of Motor Vehicles, or the Director’s designee, to investigate any matter or statements contained in this application.
I understand that if this Application for a Commercial Requester Account is approved, I will be required to conform to the statements presented within. I further understand that I will be required to sign an agreement which will become part of this application. This application and the agreement specify the terms and conditions of our relationship. Any deviations will be considered by the Department of Motor Vehicles as misuse, and may result in both revocation of the account and refusal of subsequent applications.
I understand that according to provisions of the California Vehicle Code Section 1808.45, the willful, unauthorized disclosure of information from any department record for a purpose other than the one stated in the request or the sale or other distribution of the information to a person or organization not disclosed in the request is a misdemeanor, punishable by a fine not exceeding $5,000 or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment.
I understand that according to provisions of the California Vehicle Code Section 1808.46, any person holding a requester code who directly or indirectly obtains information from the Department of Motor Vehicles using false representations or distributes restricted or confidential information to any person or uses the information for a reason not authorized or specified in this application is liable to the Department of Motor Vehicles for civil penalties up to $100,000 and shall have their requester code privileges suspended for a period of up to five (5) years or revoked.
EXECUTED AT (CITY) (COUNTY) ON (DATE)
A. Individual: I certify under the penalty of perjury that I am the sole owner as shown on this application, and that no other person is
associated in the ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE
X
B. Partnership: We certify under the penalty of perjury that we are co-partners as shown on this application and that no other person is
associated in the ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE SIGNATURE
X X
C. Corporation:I certify under the penalty of perjury that I am a corporate officer authorized to sign for the corporation identification number
and the state shown on this application are valid and that all answers and information contained within this application are true & correct
SIGNATURE OF CORPORATE OFFICER AUTHORIZED TO SIGN FOR CORPORATION TITLE
X X
___________________________________________________________________________________________________________________________________________________________________
NOTE: Branch locations may be assigned separate requester codes by completing the form Requester Codes for Branch Locations (INF 1106BL). A Separate application is required for any location operating under a different ownership.
INFORMATION SERVICES PROGRAM
COMMERCIAL REQUESTER ACCOUNT AGREEMENT
A Public Service Agency DMV AGREEMENT NUMBER_________________
Instructions: Read and complete as indicated
A. GENERAL PROVISIONS
1. This Agreement is between the State of California, Department of Motor Vehicles (DMV), hereinafter referred to as the “DMV”, and __________________________________________, hereinafter referred to as “Requester”, for the purpose of the DMV providing information from its files for commercial uses. Each Requester selling information to another Requester will be defined as a “Vendor” for the purposes of this Agreement. Requesters receiving information for an authorized use or purpose will be defined as an “End User” for the purposes of this Agreement.
2. To receive information, the Requester shall submit a completed Application for a Commercial Requester Account (INF 1106A, E or V) which, when approved by DMV, will be incorporated as part of this Agreement. No service to a requester shall be provided prior to DMV’s written approval and assignment of a requester code.
3. If the Requester is a DMV approved Agent acting on behalf of a dealer, vehicle manufacturer, a government entity, or empolyer enrolled in the Employer Pull Notice Program, authorization from the dealer, vehicle manufacturer, the government entity, or employer to act on their behalf shall be submitted on a form prescribed by DMV.
4. The term of this Agreement shall be for twenty-four (24) months from the approval date of the original Commercial Requester Account Application (INF 1106A, E or V) and thereafter, renewable at two year intervals.
5. This Agreement is subject to any restrictions, limitations or provisions enacted by the California State Legislature which may affect the provisions or terms set forth herein. The Requester is required to comply with the applicable statutes of the California Vehicle Code (CVC) and California Code of Regulations (CCR) Title 13.
6. No alteration or variation of the terms of this Agreement shall be valid unless made in writing and signed by both parties hereto, and no oral understanding or agreement, not incorporated herein, shall be binding on either party.
7. The Requester shall not represent themselves as agents or employees of DMV. For the purposes of this agreement, the Requester includes the officers, partners, owners, and employees of the Requester.
8. Requester agrees to defend, indemnify, and hold harmless DMV and its employees or agents from any and all claims, actions, damages, or losses which may be brought or alleged against its employees or agent for the negligent, improper, or unauthorized use or dissemination by the Requester of information furnished to the Requester by DMV or by reason of inaccurate information furnished to the Requester by DMV.
9. This Agreement is not assignable by the Requester, either in whole or in part, without prior written consent of DMV.
10. a. Any promotional or informational material related to accessing the DMV’s records shall be accurate and shall be consistent with the terms and provisions of this Agreement and Commercial Requester Account Application (INF 1106A, E or V) and shall contain only factual statements relating to the purpose and conditions of access as set forth in this Agreement.
b. The Requester shall not use the logotype in any advertising or other business materials used in the business of the Requester. The advertising shall neither state nor infer that there is any official connection between DMV and the advertiser, or that DMV has sanctioned or approved of either the advertisement or the advertiser’s service.
11. Requester shall notify DMV in writing within one business day of any intended or actual closure of the Requester’s business enterprise or voluntary termination of the Commercial Requester Account and within ten working days of changes in sole ownership, partnership, or corporate principal staff officers, contact person, address, or of any other change in the Commercial Requester Account Application (INF 1106A, E or V). Notification shall be sent to:
Department of Motor Vehicles
Information Services Branch
Account Processing Unit, H264
P.O. Box 944231
Sacramento, CA 94244-2310
12. Requester’s access to DMV information may be modified and/or terminated immediately with cause.
13. Requester’s access to DMV information may be modified and/or terminated without cause upon 30 days notice by either party.
B. INFORMATION USE
1. DMV retains ownership of all information extracted from its files.
2. Requester shall not use DMV records for any purpose except for that which had been approved by DMV.
3. Information received from DMV shall not be retained, stored, combined and/or linked with any other data on any database for any reason without prior written approval from DMV. Any such written approval shall then become an attachment, subject to the terms of this agreement.
4. When information is received from DMV indicating a vehicle or vessel has a Department of Justice (DOJ) stop on the record, the Requester shall immediately notify local law enforcement of its location, if known, and the identity of the ultimate Requester (i.e., End User), if different. The vehicle shall not be sold or transferred by the Requester until a law enforcement agency clears and removes the DOJ stop on the record.
C. SECURITY
General Security Requirements
1. Requester shall maintain the security and integrity of the information it receives. A violation of any provisions of this Agreement, whether by omission or commission, shall be grounds for action by DMV and may result in suspension or termination of service to the Requester. DMV may pursue appropriate administrative, civil, and/or criminal action for violation of Agreement provisions in accordance with the CVC § 1808.45, § 1808.46 and § 1808.47.
2. Requester shall ensure compliance with all security provisions of this agreement. If fraud or abuse is suspected or confirmed, Requester shall notify DMV’s Information Services Policy and Automation Section by telephone at (916) 657-5583 within one business day.
A written notification containing all facts therin shall be prepared by the Requester within three business days and mailed to DMV at the following address:
Department of Motor Vehicles
Information Services Branch
Policy and Automation Section – H225
P.O. Box 942890
Sacramento, CA 94290-0001
3. Requesters shall require every employee and the system administrator having direct or incidental access to DMV records, to sign a copy of the Employee Security Statement (INF 1128) upon initial authorization for access to DMV records and annually thereafter. A copy of the signed statement shall be maintained at the requester’s worksite for at least two years following the deactivation or termination of the authorization and shall be available to the DMV upon demand.
4. Requester shall restrict the use and knowledge of requester codes and operational manuals to persons who have signed an Employee Security Statement (INF 1128).
5. Requester shall maintain a current list of names and individuals authorized to access DMV records. This list shall be available to the DMV upon demand.
6. Requester shall maintain a current list of end user terminals and the number of users for each terminal. This list shall be available to DMV upon demand.
7. Access terminals and modems shall not be left unattended while in active session unless secured by a locking device that prevents entry or receipt of information or placed in a locked room that is not accessible to unauthorized persons. Access terminals displaying DMV data shall display a “sign-on banner” containing some variation of the following admonishment: “WARNING: Unauthorized access or misuse of data may result in adverse action and/or criminal prosecution”.
8. Video terminals, printers, hardcopy printouts or any other forms of duplication of DMV approved records located in public access areas shall be placed so that the records shall not be viewed by the public or other unauthorized persons.
9. All information received from the DMV’s files must be destroyed once its legitimate use has ended. The method of destruction of DMV records should be in a manner that it cannot be reproduced or identified in any physical or electronic form.
10. Each DMV approved Agent shall maintain a log of the request for a period of two years from the date of the request. The log shall be immediately available for review at DMV’s request. The log format shall provide the following in the order presented:
• Date of request
• Type of information requested
• Whether residence address was given
• Identity of whom the information was provided
11. Each DMV approved Vendor shall maintain a log of the request for a period of five years from the date of the request. The log shall be
immediately available for review at DMV’s request. The log format shall provide the following in the order presented:
• Date of request
• Type of information requested
• Whether residence address was given
• Identity of whom the information was provided (including “Intermediate Vendors”)
• Identify proposed use of information (as approved by DMV.)
12. Each DMV approved Vendor or Agent, must ensure that the receiver of the requested records is an approved Requester [CVC §
1808.46].
13. Requester shall not disclose its DMV assigned requester code verbally, in writing, or when passing data electronically, to anyone other than a DMV approved Vendor or Agent, who is not in the direct employ of the Requester or who has not signed the Employee Security Statement (INF 1128).
14. Vendor shall block transmission of its requester code to an End User. Vendor shall not display any DMV assigned requester code during a demonstration of on-line information service.
15. Requesters shall not sell, retain, distribute, provide, or transfer any record information or portion of the record information acquired under this Agreement except as authorized by the DMV.
D. RESIDENCE ADDRESS ACCESS AUTHORITY
1. Upon approval for residence address access, Requester shall protect the confidentiality of any residence address received from DMV records, pursuant to CVC § 1808.47. Requester employees shall not obtain or use any confidential or restricted records for any purpose other than the reason the information was requested.
2. Requester may release residence or mailing address information to an individual, other than an employee, who is acting on behalf of the Requester provided a Representative Non-Disclosure Statement (INF 1110) acknowledging the confidentiality of residence address information pursuant to CVC § 1808.47, is signed by the individual with whom the Requester has contracted services. This form shall be filed at the Requester’s business location as shown on the Commercial Requester Account Application (INF 1106A, E or V), be completed annually, and retained for two years.
3. Requesters approved to receive confidential residence address information shall maintain a log of the request for two years from the date of the request. The log shall be immediately available for review at DMV’s request. The log format shall provide the following in the order presented:
• Requester code used to make the request
• Date of the request
• Type of information requested
• Points of identification used for the request (e.g., license # and DOB)
• Business reason for the request
Any Requester except Dealers or Vehicle Manufacturers, including their agents, shall also maintain a copy of the business or legal document that justifies or supports each request and be available to DMV with the log.
4. Requester’s authority to receive residence address information is based on the following:
( Financial Institution ( Insurance Company ( Attorneys ( Statistical Research/Reporting
CVC § 1808.22(a) CVC § 1808.22(b) CVC § 1808.22(c) CVC § 1808.23(c)
( Dealers or Dealer Agents ( Vehicle Manufacturers or Vehicle Manufacturers Agents
CVC § 1808.23(b) CVC § 1808.23(a)
( Other – Insert State or Federal Statute, below (identify by code name and section #):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
E. AUDIT
1. Requester’s documentation supporting the reason for inquiry, including but not limited to, transaction details and billing documents, computer software and programs maintained for the purposes defined in this Agreement, shall be subject to inspection, review or audit by DMV or its representative for a period of two years from the date of the request at no cost to the DMV. Requester agrees to accommodate DMV’s request for an inspection, review or audit immediatley upon request and to allow on-site audits during regular business hours.
2. Whenever a Commercial Requester Account is terminated with or without cause,or voluntarily closed pursuant to CCR §350.16(b), DMV may require the holder to surrender, to DMV, all records retained pursuant to CCR §350.48 and CCR §350.18(b)(4)(5), not later than the end of the third business day following the date os suspension, revocation, or closure. The notification to surrender the records shall be included in the notice of suspension or revocation and shall be delivered to the address indicated below no later than the end of the twentieth (20th) departmental business day following the Department’s notification to surrender.
Office of Investigations/Audits
Compliance Audits Unit
2570 24th Street
Sacramento, California 95818
F. FEES
1. The Requester shall pay the appropriate fees pursuant to CCR §350.44.
2. Requesters receiving information directly from the DMV shall be billed monthly. The bill shall be payable, in full, upon receipt. If any amount remains unpaid sixty (60) days after the invoice date, the Requester’s access codes may be revoked. If the Requester disputes the amount of bill and notifies DMV in writing within thirty (30) days of the invoice date, access codes may not be revoked until thirty (30) days after DMV confirms the amount of the disputed bill and rebills the Requester.
G. SERVICE OF PROCESS
a. Requester agrees to accept service of process by registered mail to the Commercial Requester Account address last filed with DMV.
b. If Requester has no place of business in California, Requester hereby appoints:
Name of individual__________________________________________________________________________________________
Business/Residence Address_________________________________________________________________________________
City _______________________________________________ State__________________________ Zip Code ______________
as Requester’s true and lawful agent upon whom all process may be served in any action, or actions, which may thereafter be commenced against said Requester, arising out of any cause of action by reason of the violation of said Requester or any of the terms and provisions of the CVC and this Agreement (Title 13, CCR 350.02 et seq.).
Requester further stipulates and agrees that, when personal service of process upon Requester’s appointee named herein, cannot be made after due diligence, that service can be made upon the Director of DMV, or in the event of the Director’s absence from his/her office, that service can be made upon any employee ot he State of California in charge of the Director’s office, and that such service of process shall be of the same legal force and effect as if serviced upon Requester personally; that Requester further stipulates and agrees that the agency created by said appointment shall continue for and during period covered by this Agreement when authorized by the DMV and so long thereafter as the Requester may be made to answer in damages for violation of the laws, regulations, or rule of the court as identified in this Agreement; Requester further agrees that for the purpose of venue, whenever service is made upon the Director, the service shall be deemed to have been made upon the Requester in the county in which Requester has or last had his appointed agent.
H. SIGNATURE REQUIREMENTS
This Agreement shall be signed by a corporate officer, partner, or sole owner of the entity designated as the Requester on the Commercial Account Application (INF 1106A, E or V) and said person shall be responsible for administering the provisions within this agreement and for the orientation, training and supervision of persons authorized access DMV’s record information.
I certify under penalty of perjury, under the laws of the State of Calilfornia, that I have read and understand the aforementioned statements, and agree to comply with the requirements contained therein and, if approved to receive residence address information, that measures have been instituted to ensure that each request for residence address from the files of DMV is used pursuant to the identified federal or state statute.
Executed at _____________________________________ , ____________________________________ , _____________________
CITY COUNTY STATE
Date _____________________ Signature X_______________________________________________________________________
Print Name and Title __________________________________________________________________________________________
Approved by DMV Representative:
Date _____________________ Signature X_______________________________________________________________________
Print Name and Title __________________________________________________________________________________________
INFORMATION SERVICES PROGRAM
COMMERCIAL REQUESTER ACCOUNT AGREEMENT
A Public Service Agency DMV AGREEMENT NUMBER_________________
Instructions: Read and complete as indicated
A. GENERAL PROVISIONS
1. This Agreement is between the State of California, Department of Motor Vehicles (DMV), hereinafter referred to as the “DMV”, and __________________________________________, hereinafter referred to as “Requester”, for the purpose of the DMV providing information from its files for commercial uses. Each Requester selling information to another Requester will be defined as a “Vendor” for the purposes of this Agreement. Requesters receiving information for an authorized use or purpose will be defined as an “End User” for the purposes of this Agreement.
2. To receive information, the Requester shall submit a completed Application for a Commercial Requester Account (INF 1106A, E or V) which, when approved by DMV, will be incorporated as part of this Agreement. No service to a requester shall be provided prior to DMV’s written approval and assignment of a requester code.
3. If the Requester is a DMV approved Agent acting on behalf of a dealer, vehicle manufacturer, a government entity, or empolyer enrolled in the Employer Pull Notice Program, authorization from the dealer, vehicle manufacturer, the government entity, or employer to act on their behalf shall be submitted on a form prescribed by DMV.
4. The term of this Agreement shall be for twenty-four (24) months from the approval date of the original Commercial Requester Account Application (INF 1106A, E or V) and thereafter, renewable at two year intervals.
5. This Agreement is subject to any restrictions, limitations or provisions enacted by the California State Legislature which may affect the provisions or terms set forth herein. The Requester is required to comply with the applicable statutes of the California Vehicle Code (CVC) and California Code of Regulations (CCR) Title 13.
6. No alteration or variation of the terms of this Agreement shall be valid unless made in writing and signed by both parties hereto, and no oral understanding or agreement, not incorporated herein, shall be binding on either party.
7. The Requester shall not represent themselves as agents or employees of DMV. For the purposes of this agreement, the Requester includes the officers, partners, owners, and employees of the Requester.
8. Requester agrees to defend, indemnify, and hold harmless DMV and its employees or agents from any and all claims, actions, damages, or losses which may be brought or alleged against its employees or agent for the negligent, improper, or unauthorized use or dissemination by the Requester of information furnished to the Requester by DMV or by reason of inaccurate information furnished to the Requester by DMV.
9. This Agreement is not assignable by the Requester, either in whole or in part, without prior written consent of DMV.
10. a. Any promotional or informational material related to accessing the DMV’s records shall be accurate and shall be consistent with the terms and provisions of this Agreement and Commercial Requester Account Application (INF 1106A, E or V) and shall contain only factual statements relating to the purpose and conditions of access as set forth in this Agreement.
b. The Requester shall not use the logotype in any advertising or other business materials used in the business of the Requester. The advertising shall neither state nor infer that there is any official connection between DMV and the advertiser, or that DMV has sanctioned or approved of either the advertisement or the advertiser’s service.
11. Requester shall notify DMV in writing within one business day of any intended or actual closure of the Requester’s business enterprise or voluntary termination of the Commercial Requester Account and within ten working days of changes in sole ownership, partnership, or corporate principal staff officers, contact person, address, or of any other change in the Commercial Requester Account Application (INF 1106A, E, or V). Notification shall be sent to:
Department of Motor Vehicles
Information Services Branch
Account Processing Unit, H264
P.O. Box 944231
Sacramento, CA 94244-2310
12. Requester’s access to DMV information may be modified and/or terminated immediately with cause.
13. Requester’s access to DMV information may be modified and/or terminated without cause upon 30 days notice by either party.
B. INFORMATION USE
1. DMV retains ownership of all information extracted from its files.
2. Requester shall not use DMV records for any purpose except for that which had been approved by DMV.
3. Information received from DMV shall not be retained, stored, combined and/or linked with any other data on any database for any reason without prior written approval from DMV. Any such written approval shall then become an attachment, subject to the terms of this agreement.
4. When information is received from DMV indicating a vehicle or vessel has a Department of Justice (DOJ) stop on the record, the Requester shall immediately notify local law enforcement of its location, if known, and the identity of the ultimate Requester (i.e., End User), if different. The vehicle shall not be sold or transferred by the Requester until a law enforcement agency clears and removes the DOJ stop on the record.
C. SECURITY
General Security Requirements
1. Requester shall maintain the security and integrity of the information it receives. A violation of any provisions of this Agreement, whether by omission or commission, shall be grounds for action by DMV and may result in suspension or termination of service to the Requester. DMV may pursue appropriate administrative, civil, and/or criminal action for violation of Agreement provisions in accordance with the CVC § 1808.45, § 1808.46 and § 1808.47.
2. Requester shall ensure compliance with all security provisions of this agreement. If fraud or abuse is suspected or confirmed, Requester shall notify DMV’s Information Services Policy and Automation Section by telephone at (916) 657-5583 within one business day.
A written notification containing all facts therin shall be prepared by the Requester within three business days and mailed to DMV at the following address:
Department of Motor Vehicles
Information Services Branch
Policy and Automation Section – H225
P.O. Box 942890
Sacramento, CA 94290-0001
3. Requesters shall require every employee and the system administrator having direct or incidental access to DMV records, to sign a copy of the Employee Security Statement (INF 1128) upon initial authorization for access to DMV records and annually thereafter. A copy of the signed statement shall be maintained at the requester’s worksite for at least two years following the deactivation or termination of the authorization and shall be available to the DMV upon demand.
4. Requester shall restrict the use and knowledge of requester codes and operational manuals to persons who have signed an Employee Security Statement (INF 1128).
5. Requester shall maintain a current list of names and individuals authorized to access DMV records. This list shall be available to the DMV upon demand.
6. Requester shall maintain a current list of end user terminals and the number of users for each terminal. This list shall be available to DMV upon demand.
7. Access terminals and modems shall not be left unattended while in active session unless secured by a locking device that prevents entry or receipt of information or placed in a locked room that is not accessible to unauthorized persons. Access terminals displaying DMV data shall display a “sign-on banner” containing some variation of the following admonishment: “WARNING: Unauthorized access or misuse of data may result in adverse action and/or criminal prosecution”.
8. Video terminals, printers, hardcopy printouts or any other forms of duplication of DMV approved records located in public access areas shall be placed so that the records shall not be viewed by the public or other unauthorized persons.
9. All information received from the DMV’s files must be destroyed once its legitimate use has ended. The method of destruction of DMV records should be in a manner that it cannot be reproduced or identified in any physical or electronic form.
10. Each DMV approved Agent shall maintain a log of the request for a period of two years from the date of the request. The log shall be immediately available for review at DMV’s request. The log format shall provide the following in the order presented:
• Date of request
• Type of information requested
• Whether residence address was given
• Identity of whom the information was provided
11. Each DMV approved Vendor shall maintain a log of the request for a period of five years from the date of the request. The log shall be
immediately available for review at DMV’s request. The log format shall provide the following in the order presented:
• Date of request
• Type of information requested
• Whether residence address was given
• Identity of whom the information was provided (including “Intermediate Vendors”)
• Identify proposed use of information (as approved by DMV.)
12. Each DMV approved Vendor or Agent, must ensure that the receiver of the requested records is an approved Requester [CVC §
1808.46].
13. Requester shall not disclose its DMV assigned requester code verbally, in writing, or when passing data electronically, to anyone other than a DMV approved Vendor or Agent, who is not in the direct employ of the Requester or who has not signed the Employee Security Statement (INF 1128).
14. Vendor shall block transmission of its requester code to an End User. Vendor shall not display any DMV assigned requester code during a demonstration of on-line information service.
15. Requesters shall not sell, retain, distribute, provide, or transfer any record information or portion of the record information acquired under this Agreement except as authorized by the DMV.
D. RESIDENCE ADDRESS ACCESS AUTHORITY
1. Upon approval for residence address access, Requester shall protect the confidentiality of any residence address received from DMV records, pursuant to CVC § 1808.47. Requester employees shall not obtain or use any confidential or restricted records for any purpose other than the reason the information was requested.
2. Requester may release residence or mailing address information to an individual, other than an employee, who is acting on behalf of the Requester provided a Representative Non-Disclosure Statement (INF 1110) acknowledging the confidentiality of residence address information pursuant to CVC § 1808.47, is signed by the individual with whom the Requester has contracted services. This form shall be filed at the Requester’s business location as shown on the Commercial Requester Account Application (INF 1106A, E or V), be completed annually, and retained for two years.
3. Requesters approved to receive confidential residence address information shall maintain a log of the request for two years from the date of the request. The log shall be immediately available for review at DMV’s request. The log format shall provide the following in the order presented:
• Requester code used to make the request
• Date of the request
• Type of information requested
• Points of identification used for the request (e.g., license # and DOB)
• Business reason for the request
Any Requester except Dealers or Vehicle Manufacturers, including their agents, shall also maintain a copy of the business or legal document that justifies or supports each request and be available to DMV with the log.
4. Requester’s authority to receive residence address information is based on the following:
( Financial Institution ( Insurance Company ( Attorneys ( Statistical Research/Reporting
CVC § 1808.22(a) CVC § 1808.22(b) CVC § 1808.22(c) CVC § 1808.23(c)
( Dealers or Dealer Agents ( Vehicle Manufacturers or Vehicle Manufacturers Agents
CVC § 1808.23(b) CVC § 1808.23(a)
( Other – Insert State or Federal Statute, below (identify by code name and section #):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
E. AUDIT
1. Requester’s documentation supporting the reason for inquiry, including but not limited to, transaction details and billing documents, computer software and programs maintained for the purposes defined in this Agreement, shall be subject to inspection, review or audit by DMV or its representative for a period of two years from the date of the request at no cost to the DMV. Requester agrees to accommodate DMV’s request for an inspection, review or audit immediatley upon request and to allow on-site audits during regular business hours.
2. Whenever a Commercial Requester Account is terminated with or without cause,or voluntarily closed pursuant to CCR §350.16(b), DMV may require the holder to surrender, to DMV, all records retained pursuant to CCR §350.48 and CCR §350.18(b)(4)(5), not later than the end of the third business day following the date os suspension, revocation, or closure. The notification to surrender the records shall be included in the notice of suspension or revocation and shall be delivered to the address indicated below no later than the end of the twentieth (20th) departmental business day following the Department’s notification to surrender.
Office of Investigations/Audits
Compliance Audits Unit
2570 24th Street
Sacramento, California 95818
F. FEES
1. The Requester shall pay the appropriate fees pursuant to CCR §350.44.
2. Requesters receiving information directly from the DMV shall be billed monthly. The bill shall be payable, in full, upon receipt. If any amount remains unpaid sixty (60) days after the invoice date, the Requester’s access codes may be revoked. If the Requester disputes the amount of bill and notifies DMV in writing within thirty (30) days of the invoice date, access codes may not be revoked until thirty (30) days after DMV confirms the amount of the disputed bill and rebills the Requester.
G. SERVICE OF PROCESS
a. Requester agrees to accept service of process by registered mail to the Commercial Requester Account address last filed with DMV.
b. If Requester has no place of business in California, Requester hereby appoints:
Name of individual__________________________________________________________________________________________
Business/Residence Address_________________________________________________________________________________
City _______________________________________________ State__________________________ Zip Code ______________
as Requester’s true and lawful agent upon whom all process may be served in any action, or actions, which may thereafter be commenced against said Requester, arising out of any cause of action by reason of the violation of said Requester or any of the terms and provisions of the CVC and this Agreement (Title 13, CCR 350.02 et seq.).
Requester further stipulates and agrees that, when personal service of process upon Requester’s appointee named herein, cannot be made after due diligence, that service can be made upon the Director of DMV, or in the event of the Director’s absence from his/her office, that service can be made upon any employee ot he State of California in charge of the Director’s office, and that such service of process shall be of the same legal force and effect as if serviced upon Requester personally; that Requester further stipulates and agrees that the agency created by said appointment shall continue for and during period covered by this Agreement when authorized by the DMV and so long thereafter as the Requester may be made to answer in damages for violation of the laws, regulations, or rule of the court as identified in this Agreement; Requester further agrees that for the purpose of venue, whenever service is made upon the Director, the service shall be deemed to have been made upon the Requester in the county in which Requester has or last had his appointed agent.
H. SIGNATURE REQUIREMENTS
This Agreement shall be signed by a corporate officer, partner, or sole owner of the entity designated as the Requester on the Commercial Account Application (INF 1106A, E or V) and said person shall be responsible for administering the provisions within this agreement and for the orientation, training ans supervision of persons authorized access DMV’s record information.
I certify under penalty of perjury, under the laws of the State of Calilfornia, that I have read and understand the aforementioned statements, and agree to comply with the requirements contained therein and, if approved to receive residence address information, that measures have been instituted to ensure that each request for residence address from the files of DMV is used pursuant to the identified federal or state statute.
Executed at _____________________________________ , ____________________________________ , _____________________
CITY COUNTY STATE
Date _____________________ Signature X_______________________________________________________________________
Print Name and Title __________________________________________________________________________________________
Approved by DMV Representative:
Date _____________________ Signature X_______________________________________________________________________
Print Name and Title __________________________________________________________________________________________
A Public Service Agency
COMMERCIAL REQUESTER ACCOUNT SURETY BOND
______________________________________________________________________________________________________________
REQUESTER ACCOUNT NUMBER BOND NUMBER
SURETY COMPANY NAME COMMERCIAL REQUESTER ACCOUNT BUSINESS NAME OF PRINCIPAL
PLACE OF BUSINESS ADDRESS PLACE OF BUSINESS ADDRESS
CITY STATE ZIP CODE CITY STATE ZIP CODE
PURPOSE
This is an agreement between the Surety and the Principal under which the Surety, its successors and assignees, are jointly and severally liable and agree to be responsible for payment up to $50,000 for any final judgment(s) or indebtedness due the department against the Principal, subject to the following governing provisions and conditions.
GOVERNING PROVISIONS
(1) The provisions of Article 3 (commencing with Section 1800) or Chatper 1 of Division 2 of the Vehicle Code
(2) The provisions of Chaper 2 (commencing with Section 995.010) of Part 2 of Title 14 of the Code of Civil Procedure
(3) Rules and Regulations, of Article 5 (commencing with Section 350.2) of Chapter 1 of Division 1 of Title 13, Code of Regulations
CONDITIONS
The Principal is required to have on file with the California Department of Motor Vehicles (DMV) a bond in the sum of $50,000. The bond shall be issued by an admitted insurance or bondng company that is licensed by the Department of Insurance to do business in California. The Principal shall:
(1) Hold DMV harmless for monetary loss(es) caused by the Principal’s misuse of the information obtained directly from DMV, up to the $50,000 secured by the bond.
(2) Pay to DMV monies due for application fees and DMV costs related to the release or access of information from DMV records to the Principal.
(3) Pay to DMV, its officers, and any other person(s), civil penalties or damages caused to DMV or to such persons by the Principal, its representative or agent, or by any person to whom the Principal sells, gives, or furnishes information received directly or indirectly by the Principal from DMV in any amount up to the $50,000 secured by the bond based on the following acts or omissions:
(a) Obtaining information from DMV by false or misleading representation(s).
(b) Using information obtained from DMV for any purpose other than specified in the Principal’s application for a commercial
requester account, and/or
(c) Selling, giving, or furnishing any information obtained from DMV records to a third party not specifically authorized and approved
by the department.
The Bond shall be deemed continuous, remain in full force and effect and run concurrently with the period for which the commercial requester account is authorized by the department.
This bond shall be canceled by the Surety in accordance with the provisions of Article 13, Sections 996.310 et seq. Of Chapter 2 or Title 14 of the California Code of Civil Procedure. The Principal shall cancel by notifying DMV in writing, thirty days prior to cancellation date at Department of Motor Vehicles, Accounts Processing MS H221, PO Box 944231, Sacramento, CA 94244-2310.
In witness whereof the said Principal and Surety have signed this ___________ day of _________________________ 19/20 _________,
___________________________________________________ X______________________________________________________
PRINT OR TYPE NAME OF PRINCIPAL OFFICER AUTHORIZED TO SIGN SIGNATURE OF PRINCIPAL
I certify under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct and that I have executed the foregoing bond under an unrevoked power of attorney.
Executed at ________________________________________ on, ______________________________________ 19/20 ___________ ,
CITY/STATE DATE
X______________________________________________________
SIGNATURE OF ATTORNEY-IN-FACT FOR SURETY
(OFFICIAL SEAL)
______________________________________________________ PRINT OR TYPE NAME OF ATTORNEY-IN-FACT FOR SURETY
A Public Service Agency
INFORMATION SERVICES PROGRAM
REPRESENTATIVE
NON-DISCLOSURE
STATEMENT
(To be completed by Representative)
REQUESTER REPRESENTATIVE
(Commercial or Government Requester Account Holder) (Representative of Requester)
COMPANY OR GOVERNMENTAL ENTITY NAME COMPANY NAME AND/OR INDIVIDUAL NAME
PHYSICAL ADDRESS PHYSICAL ADDRESS
MAILING ADDRESS MAILING ADDRESS
NAME OF CONTACT PERSON TELEPHONE NUMBER NAME OF CONTACT PERSON TELEPHONE NUMBER
A Representative is an individual, other than an employee, authorized by a requester account holder to perform a specified business function. The Representative may not directly request or receive information from DMV.
I hereby acknowledge that, pursuant to California Vehicle Code (CVC) Section 1808.21, any residence/mailing address in any record obtained from the California Department of Motor Vehicles is confidential information. I have also read and understand the provisions of Section 1808.47 CVC:
“Any person who has access to confidential or restricted information from the department shall
establish procedures to protect the confidentiality of those records. If confidential or restricted
addresses are released to any agent of a person authorized to obtain restricted addresses as
provided in Section 1808.21, 1808.22, 1810.2, or 1810.7, the person shall require the agent to
take all steps necessary to ensure confidentiality of these addresses and prevent any release of
the information to a third party. No agent shall obtain or use any confidential or restricted
records from requester code holders for any purpose other than the reason the information was
requested by the requester code holder who originally obtained the information.”
I further understand that if I am a Process Server, I must obtain my own requester account and may not receive
information from another party; therefore, I do not qualify to use this form or act as a Representative on behalf of
another for process serving unless the information was obtained pursuant to 1808.22 or 1808.23 CVC.
Pursuant to the above, I understand that the following are my responsibilities:
1. To protect the confidentiality of any residence/mailing address information provided to me by and on behalf of
Requester.
2. To promptly notify DMV of any indication of misuse or unauthorized disclosure of confidential or restricted
departmental information.
I understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant to Sections 1808.45 and l808.46 CVC.
I certify under penalty of perjury, under the laws of the State of California, that the above statements are true and correct.
EXECUTED AT CITY COUNTY STATE
DATE SIGNATURE OF REPRESENTATIVE
x
NAME AND TITLE OF SIGNATORY
This form must be completed and RETAINED AT THE WORKSITE of the Requester Account Holder with a written agreement between the Representative and the Requester Account Holder for the life of the agreement and for two years following the deactivation or termination of the agreement. This completed form and the agreement must be made available upon request to DMV Audit Staff.
A Public Service Agency
INFORMATION SERVICES PROGRAM
REPRESENTATIVE
NON-DISCLOSURE
STATEMENT
(To be completed by Representative)
REQUESTER REPRESENTATIVE
(Commercial or Government Requester Account Holder) (Representative of Requester)
COMPANY OR GOVERNMENTAL ENTITY NAME COMPANY NAME AND/OR INDIVIDUAL NAME
PHYSICAL ADDRESS PHYSICAL ADDRESS
MAILING ADDRESS MAILING ADDRESS
NAME OF CONTACT PERSON TELEPHONE NUMBER NAME OF CONTACT PERSON TELEPHONE NUMBER
A Representative is an individual, other than an employee, authorized by a requester account holder to perform a specified business function. The Representative may not directly request or receive information from DMV.
I hereby acknowledge that, pursuant to California Vehicle Code (CVC) Section 1808.21, any residence/mailing address in any record obtained from the California Department of Motor Vehicles is confidential information. I have also read and understand the provisions of Section 1808.47 CVC:
“Any person who has access to confidential or restricted information from the department shall
establish procedures to protect the confidentiality of those records. If confidential or restricted
addresses are released to any agent of a person authorized to obtain restricted addresses as
provided in Section 1808.21, 1808.22, 1810.2, or 1810.7, the person shall require the agent to
take all steps necessary to ensure confidentiality of these addresses and prevent any release of
the information to a third party. No agent shall obtain or use any confidential or restricted
records from requester code holders for any purpose other than the reason the information was
requested by the requester code holder who originally obtained the information.”
I further understand that if I am a Process Server, I must obtain my own requester account and may not receive
information from another party; therefore, I do not qualify to use this form or act as a Representative on behalf of
another for process serving unless the information was obtained pursuant to 1808.22 or 1808.23 CVC.
Pursuant to the above, I understand that the following are my responsibilities:
1. To protect the confidentiality of any residence/mailing address information provided to me by and on behalf of
Requester.
2. To promptly notify DMV of any indication of misuse or unauthorized disclosure of confidential or restricted
departmental information.
I understand and acknowledge that any failure to maintain confidentiality is both civilly and criminally punishable pursuant to Sections 1808.45 and l808.46 CVC.
I certify under penalty of perjury, under the laws of the State of California, that the above statements are true and correct.
EXECUTED AT CITY COUNTY STATE
DATE SIGNATURE OF REPRESENTATIVE
x
NAME AND TITLE OF SIGNATORY
This form must be completed and RETAINED AT THE WORKSITE of the Requester Account Holder with a written agreement between the Representative and the Requester Account Holder for the life of the agreement and for two years following the deactivation or termination of the agreement. This completed form and the agreement must be made available upon request to DMV Audit Staff.
A Public Service Agency
INFORMATION SERVICES BRANCH
EMPLOYEE SECURITY STATEMENT
(To be completed by Employer and Employee)
__ EMPLOYEE REQUESTER AND EMPLOYER
EMPLOYEE NAME: COMPANY OR GOVERNMENT ENTITY NAME:
DRIVER LICENSE OR IDENTIFICATION CARD NO. AND STATE: PHYSICAL ADDRESS:
EMPLOYEE ADDRESS: MAILING ADDRESS:
By signing this form, the employee has read, understands, agrees to its contents and realizes the penalties for non-compliance to its terms.
The Department of Motor Vehicles (DMV) collects confidential and personal information from the public to administer the various programs for which it has responsibility. DMV is committed to protect this information from unauthorized access, use, or disclosure. The following policies and regulations have been adopted to address commercial and governmental employees’ responsibilities for handling and protecting information obtained from the DMV. I understand the following are my responsibilities:
1. As an employee of a requester, I may access information only when necessary to accomplish the responsibilities of my employment. I may not access or use information from the DMV for personal reasons. (Examples of inappropriate access or misuse of DMV information include, but are not limited to: making personal inquiries or processing transactions on my own records or those of my friends or relatives; accessing information about another person, including locating their residence address, for any reason that is not related to my job responsibilities.)
2. I may disclose DMV information only to individuals who have been authorized to receive it through the appropriate procedures as regulated by DMV. Requesters of information must complete the appropriate forms, submit them to DMV as specified, and pay all applicable fees. In the case of confidential or personal information, a proper accounting of all disclosures must be made, and the subject must be notified in accordance with statute and DMV directives. (Examples of unauthorized disclosures include, but are not limited to: telling someone the address of another person when it is not an authorized diclosure or part of my job responsibilites.)
3. To keep the requester code and/or password confidential. I must take reasonable precautions to maintain the secrecy of the requester code assigned to the company or government entity that I am employed by, and/or my password. Reasonable precautions include not telling or allowing others to view my password or requester code; securing my terminal with a locking device if one has been provided; storing user documentation to sensitive programs in a secure place; and reporting any suspicious circumstances or unauthorized individuals I have observed in the work area to my supervisor.
4. To promptly notify DMV and an officer of the company named above of any indication of misuse or unauthorized disclosure of confidential or restricted information by any officer or employee of this company or government entity.
5. I hereby acknowledge that pursuant to California Vehicle Code Section 1808.21 any residence address in any record obtained from DMV is confidential information.
I have read and understand the security policies and regulations stated above. I understand that failure to comply with these policies and regulations may result in disciplinary action in accordance with Section 19572 of the government code, federal laws and regulations, and/or civil or criminal prosecution in accordance with applicable statutes against me and/or my employer. I further understand that I can undergo disciplinary action from my employer up to and including termination from employment.
I certify under penalty of perjury, under the laws of the State of California, that the foregoing statements are true and correct.
EXECUTED AT CITY COUNTY STATE
DATE EMPLOYEE SIGNATURE
X
DATE EMPLOYER
X
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
This form must be completed annually and RETAINED AT THE WORKSITE of the Requester Account Holder with a current list of employees who are authorized direct or incidental record access for the life of the agreement and for two years following the deactivation or termination of the agreement. This current completed form, the list, and the agreement must be made available upon request to DMV Audit Staff.
A Public Service Agency
INFORMATION SERVICES BRANCH
EMPLOYEE SECURITY STATEMENT
(To be completed by Employer and Employee)
__ EMPLOYEE REQUESTER AND EMPLOYER
EMPLOYEE NAME: COMPANY OR GOVERNMENT ENTITY NAME:
DRIVER LICENSE OR IDENTIFICATION CARD NO. AND STATE: PHYSICAL ADDRESS:
EMPLOYEE ADDRESS: MAILING ADDRESS:
By signing this form, the employee has read, understands, agrees to its contents and realizes the penalties for non-compliance to its terms.
The Department of Motor Vehicles (DMV) collects confidential and personal information from the public to administer the various programs for which it has responsibility. DMV is committed to protect this information from unauthorized access, use, or disclosure. The following policies and regulations have been adopted to address commercial and governmental employees’ responsibilities for handling and protecting information obtained from the DMV. I understand the following are my responsibilities:
1. As an employee of a requester, I may access information only when necessary to accomplish the responsibilities of my employment. I may not access or use information from the DMV for personal reasons. (Examples of inappropriate access or misuse of DMV information include, but are not limited to: making personal inquiries or processing transactions on my own records or those of my friends or relatives; accessing information about another person, including locating their residence address, for any reason that is not related to my job responsibilities.)
2. I may disclose DMV information only to individuals who have been authorized to receive it through the appropriate procedures as regulated by DMV. Requesters of information must complete the appropriate forms, submit them to DMV as specified, and pay all applicable fees. In the case of confidential or personal information, a proper accounting of all disclosures must be made, and the subject must be notified in accordance with statute and DMV directives. (Examples of unauthorized disclosures include, but are not limited to: telling someone the address of another person when it is not an authorized diclosure or part of my job responsibilites.)
3. To keep the requester code and/or password confidential. I must take reasonable precautions to maintain the secrecy of the requester code assigned to the company or government entity that I am employed by, and/or my password. Reasonable precautions include not telling or allowing others to view my password or requester code; securing my terminal with a locking device if one has been provided; storing user documentation to sensitive programs in a secure place; and reporting any suspicious circumstances or unauthorized individuals I have observed in the work area to my supervisor.
4. To promptly notify DMV and an officer of the company named above of any indication of misuse or unauthorized disclosure of confidential or restricted information by any officer or employee of this company or government entity.
5. I hereby acknowledge that pursuant to California Vehicle Code Section 1808.21 any residence address in any record obtained from DMV is confidential information.
I have read and understand the security policies and regulations stated above. I understand that failure to comply with these policies and regulations may result in disciplinary action in accordance with Section 19572 of the government code, federal laws and regulations, and/or civil or criminal prosecution in accordance with applicable statutes against me and/or my employer. I further understand that I can undergo disciplinary action from my employer up to and including termination from employment.
I certify under penalty of perjury, under the laws of the State of California, that the foregoing statements are true and correct.
EXECUTED AT CITY COUNTY STATE
DATE EMPLOYEE SIGNATURE
X
DATE EMPLOYER
X
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
This form must be completed annually and RETAINED AT THE WORKSITE of the Requester Account Holder with a current list of employees who are authorized direct or incidental record access for the life of the agreement and for two years following the deactivation or termination of the agreement. This current completed form, the list, and the agreement must be made available upon request to DMV Audit Staff.
A Public Service Agency
INFORMATION SERVICES
CERTIFICATION OF AGENCY
PLEASE CHECK THE APPROPRIATE BOX BELOW:
( My business is a vehicle dealership licensed to do business in the state of California.
( My business is a vehicle manufacturer licensed to do business in the state of California.
PLEASE PRINT THE FOLLOWING INFORMATION REGARDING YOUR OWN BUSINESS:
NAME
ADDRESS STREET CITY STATE ZIP CODE
DEALER/MANUFACTURER LICENSE NUMBER DAYTIME TELEPHONE NUMBER
( )
I hereby certify, under penalty of perjury, that the party specified below is authorized to act as my agent for the purpose of obtaining information from the Department of Motor Vehicles pursuant to Vehicle Code Section 1808.23.
In making this authorization, I agree to:
Hold the Department harmless from any monetary loss to the Department by reason of the use of information obtained from the Department by this agent; and
Pay to the Department, its officers, and any other person(s) all civil damages occasioned to the Department or such persons by reason of the following acts or omissions by this agent:
(a) obtaining information from the Department by means of false or misleading representations, or
(b) selling, giving, or otherwise furnishing any information obtained from Department records to any third
party not specifically authorized and approved by the Department.
PLEASE PRINT THE FOLLOWING INFORMATION REGARDING THE AGENT YOU ARE AUTHORIZING
NAME
ADDRESS STREET CITY STATE ZIP CODE
DRIVER LICENSE NUMBER TELEPHONE NUMBER
( )
I certify, under penalty of perjury, that the foregoing is true and correct.
EXECUTED AT CITY COUNTY STATE
DATE SIGNATURE OF DEALER OR MANUFACTURER
X
INFORMATION SERVICES PROGRAM
COMMERCIAL REQUESTER ACCOUNT NOTICE OF CHANGE
A Public Service Agency SUBMIT WITHIN 10 DAYS OF OCCURRENCE
PLEASE PRINT CLEARLY OR TYPE
Check one: ( Sole Ownership ( Partnership ( Corporation
PART A: INFORMATION ON RECORD
REQUESTER CODE(S) AGREEMENT NO. TELEPHONE NUMBER
( )
NAME OF INDIVIDUAL, PARTNERSHIP, OR CORPORATION
FIRM OR TRADE NAME
DBA
PLEASE REPORT ALL CHANGES IN THE APPROPRIATE SPACES
PART B: CORPORATE OFFICERS.
NOTE: A CHANGE IN OFFICER(S) OR IN CORPORATE NAME (SAME OFFICERS) REQUIRES COMPLETION OF THIS FORM. A CHANGE IN SOLE OWNER, PARTNER, SALE OF COMPANY, OR COMPANY MERGER REQUIRES A NEW APPLICATION AND AGREEMENT.
INSTRUCTIONS: Please list all current and new officers.
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
PART C: REPORT OF NEW FIRM NAME, MAILING ADDRESS, PHONE NUMBER, CONTACT PERSON, AUTHORIZED
PERSON OR STORAGE.
NEW FIRM NAME
NEW MAILING ADDRESS NEW DAYTIME PHONE NUMBER ( )
NEW CONTACT PERSON NEW DAYTIME PHONE NUMBER ( )
RECORD STORAGE ADDRESS (PHYSICAL LOCATION WHERE RECORDS WILL BE MAINTAINED FOR ON-SITE INSPECTION, REVIEW OR AUDIT BY DMV OR ITS REPRESENTATIVES)
CITY STATE ZIP CODE
PART D: BILLING CONTACT AND ADDRESS
BILLING CONTACT NAME (FIRST,MI,LAST)
MAILING ADDRESS CITY STATE ZIP CODE
PART E: BRANCH(S) LOCATION
INSTRUCTIONS: Please complete the Commercial Requester Account Requester Codes for Branch Location, INF1106BL.
PART F: DIRECT ON-LINE REQUESTERS ONLY
NEW ADDRESS CONTROL ADMINISRATOR-NAME(LAST,FIRST,MI) TITLE DL/ID NUMBER AND STATE ISSUED
NEW REVIEW SECURITY ADMINISTRATOR-NAME (LAST,FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED
Department of Motor Vehicles
Return completed form to: Accounts Processing Unit – H221
P.O. Box 944231
Sacramento, CA 94244-2310
PART G: ACCOUNT PURPOSES, TYPE OF RECORDS AND ADDRESS ACCESS
(NOTE: PROVIDE NEW OR ADDITIONAL INFORMATION)
INSTRUCTIONS: Complete a separate section for each purpose and explain how the information received will be used under proposed use, select the types of records requested. Check either “yes” or “no” for confidential residence address information. If yes, the Commercial Requester Account Agreement requires the specific regulation, rule of court, federal, or state statute identified by code name and section number which authorizes the use of Department of Motor Vehicle residence address information.
Type Record Abbreviations Guide
DL/ID-Driver License/Identification Card VR-Vehicle/Vessel Registration FR-Financial Responsibility OL-Occupational Licensee DMV USE ONLY
Proposed Use
1. Identify Proposed Use: _______________________________________________________________________________ Approved
( Yes ( No
___________________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR ( Residence Address: ( Yes ( No _______________
Req. Code #
Proposed Use
2. Identify Proposed Use: _______________________________________________________________________________ Approved
( Yes ( No
___________________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR ( Residence Address: ( Yes ( No _______________
Req. Code #
Proposed Use
3. Identify Proposed Use: _______________________________________________________________________________ Approved
( Yes ( No
___________________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR ( Residence Address: ( Yes ( No _______________
Req. Code #
Proposed Use
4. Identify Proposed Use: _______________________________________________________________________________ Approved
( Yes ( No
___________________________________________________________________________________________________
Type: ( VR ( DL ( OL ( FR ( Residence Address: ( Yes ( No _______________
Req. Code #
PART H: STATEMENT OF UNDERSTANDING, CERTIFICATION SIGNATURE(S)
INSTRUCTIONS: Please read the statement of understanding, complete the “Executed at” line and sign A, B, or C, as appropriate.
o I understand the false or misleading answers are cause for denial of an application and/or termination of any access agreement granted. I authorize the Director of the Department of Motor Vehicles, or the Director’s designee, to investigate any matter or statements contained in this application.
I understand that if this Application for a Commercial Requester Account is approved, I will be required to conform to the statements presented within. I further understand that I will be required to sign an agreement which will become part of this application. This application and the agreement specify revocation of the account and refusal of subsequent applications.
I understand that according to provisions of the California Vehicle Code Section 1808.45, the willful, unauthorized disclosure of information from any department record for a purpose other than the one stated in the request or the sale or other distribution of the information to a person or organization not disclosed in the request is a misdemeanor, punishable by a fine not exceeding $5,000 or by imprisonment in the county jail not exceeding one year, or both fine and imprisonment.
I understand that according to provisions of the California Vehicle Code Section 1808.46, any person holding a requester code who directly or indirectlly obtains information from the Department of Motor Vehciles using false representations or distributes restricted or confidential information to any person or uses the information for a reason not authorized or specified in this application is liable to the Department of Motor Vehicles for civil penalties up to $100,000 and shall have their requester code privileges suspended for a period of up to five (5) years or revoked.
EXECUTED AT (CITY) (COUNTY) ON (DATE)
A Individual: I certify under the penalty of perjury that I am the sole Owner as shown on this applcation, and that no person is associated in the ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE
x
B. Partnership: We certify under the penalty of perjury that we are co-partners as shown on this application and that no other person is associated in the
ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE SIGNATURE
x x
C. Corporation: I certify under the penalty of perjury that I am a corporate officer authorized to sign for the corporation identification number and the state
shown on this application are valid and that all answers and information contained within this application are true and correct.
SIGNATURE OF CORPORATE OFFICER AUTHORIZED TO SIGN FOR CORPORATION TITLE
X
A Public Service Agency Commercial Requester Account Application
Requester Codes for Branch Locations
NOTE: Complete only if you want any branch location to have their own separate requester code(s).
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PART A: Main Office
NAME OF INDIVIDUAL, PARTNERSHIP, OR CORPORATION REQUESTER CODE (IF ISSUED) AGREEMENT NUMBER (IF ISSUED)
FIRM OR TRADE NAME DBA
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
RECORD STORAGE ADDRESS (PHYSICAL LOCATION WHERE RECORDS WILL BE MAINTAINED FOR ON-SITE INSPECTION, REVIEW OR AUDIT BY DMV OR ITS REPRESENTATIVES)
(IF SAME, AS ABOVE, SO STATE CITY STATE ZIP CODE
PART B: Billing Information
Additional requester codes may be assigned to branch locations. The monthly billing invoice is automatically mailed to the branch unless you indicate that you want the billing invoice mailed to the main office.(Check one box only) ( Main office ( Branch(es)
PART C: Branch(es)
Instructions: Complete the following information for each branch location: The name of the contact person (if not the same as main office), telephone number, the street and mailing address (if different) for each branch. Requester Code Access: If the main office and specified branch(es) are to have the same type of access mark “same”. If receiving residence address information and the branch(es) are to be restricted to basic record information only mark “Basic”. If more space is needed, see Part F on reverse side of form.
Req Code DMV USE ONLY
PART D: Branch Contact Person and Address Information Access Requester Code(s)
SAME BASIC
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
PART E: Execution Statement and Signatures
Instructions: Please complete the execution statement. Partnerships require signature of all partners (if more than two, sign on the same line and print name). Corporations require the signature of corporate officer authorized to sign for corporation.
EXECUTED AT (CITY) (COUNTY) ON (DATE)
A. Individual: I certify under the penalty of perjury that I am the sole owner of the business and that no other person is associated in the ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE
x
B. Partnership: We certify under the penalty of perjury that we are co-partners and that no other person is associated in the ownership of the business, and that all answers and information contained within this application are true and correct.
SIGNATURE SIGNATURE
X x
C. Corporation: I certify under the penalty of perjury that I am a corporate officer authorized to sign for the corporation and that all answers and information contained within this application are true and correct.
SIGNATURE OF CORPORATE OFFICER AUTHORIZED TO SIGN FOR CORPORATION TITLE
x x
Commercial Requester Account Application Page ____ of ____
Requester Codes for Branch Locations _________________
(Continued) NAME OF MAIN OFFICE
If additional space is needed, you may photocopy this side or request additional copies by contacting the Account Processing Unit,
P.O. Box 944231, Mail Station H221, Sacramento, CA 94244-2310 (916) 657-5564. Complete the page number as indicated.
Req Code DMV USE ONLY
PART F: Branch Contact Person and Address Information Access Requester Code(s)
SAME BASIC
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
CONTACT PERSON (LAST,FIRST,MI) TELEPHONE NO.
STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
-----------------------
DMV USE ONLY
CHECK/M.O. NUMBER CHECK/M.O. AMOUNT
$
REFUND AGREEMENT NUMBER ISSUED
$
CA ID/DATE EXPIRES
DMV USE ONLY
Proposed use Approved
( Yes ( No
Req. Code #
Proposed use Approved
( Yes ( No
Req. Code #
Proposed use Approved
( Yes ( No
Req. Code #
Proposed use Approved
( Yes ( No
Req. Code #
DMV USE ONLY
[pic]
DMV USE ONLY
DATE APPROVED
EXPIRATION DATE
DMV USE ONLY
DATE APPROVED
EXPIRATION DATE
Proposed use Approved
( Yes ( No
Req. Code #
Proposed use Approved
( Yes ( No
Req. Code #
Proposed use Approved
( Yes ( No
Req. Code #
Proposed use Approved
( Yes ( No
Req. Code #
DMV USE ONLY
REFUND AGREEMENT NUMBER ISSUED
$
CA ID/DATE EXPIRES
CHECK/M.O. NUMBER CHECK/M.O. AMOUNT
$
DMV USE ONLY
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