MVR State Forms *HireRight, LLC. is required by the state DMV to keep this form signed and on file. Subscriber Certificate of Use State of Delaware - Motor Vehicle Records (MVR s) and Additional Driver Discovery (ADD) Reports (Company Name) hereby certifies to HireRight, LLC. and the State of Delaware, Division of Motor Vehicles that any and all driver abstract information obtained from State of Delaware through HireRight, LLC. shall be used exclusively for the permitted purposes as defined under the laws of the State of Delaware and the Federal Fair Credit Reporting Act ( FCRA ). further certifies that such information shall be used solely by shall not be sold, assigned or otherwise transferred to any other party or entity. (Company Name) (Company Name) Subscriber: (Address) By: Date:
GEORGIA DEPARTMENT OF DRIVE SERVICES BULK MVR USER CERTIFICATE User Name: Address: City: State: Zip Code: Telephone #: Fax: Email: Bulk Requestor Used? Yes No If yes, Name: HireRight The company or individual named above certifies that for each driving record requested, the information contained therein shall be used solely for one of the following approved purposes: insurance claims investigation, insurance antifraud activities, insurance rating, insurance underwriting, car rental agreements, address verification by a creditor, or as part of a background investigation on an employee or applicant for employment. In the event that an adverse decision is based upon any information supplied to the User by the Department of Driver Services (DDS), then upon request of the driver named in the driving record, the User of the producing insurance agent, if applicable, shall inform the driver named in the record of all information pertinent to the decision. This provision is to be construed as requiring the User to include specific information included in the driver s record. All information is requested only for the User s exclusive use. The User shall not share, sell or otherwise disseminate any information included in the motor vehicle report to any other person or company, excepts as provided in O.C.G.A. 40-5-2, 18 U.S.C. 2721, et seq., Ga. Admin. Comp. Ch. 375-3-8-.03, any other applicable provision of law, or as provided herein. Any violation of the rules, laws or agreements applicable to the access provided herein to the User shall be considered sufficient grounds for the DDS to refuse to release any additional information on any other driver that the User may request. This administrative action by the DDS shall not be deemed to supersede any other sanctions prescribed by law, including, but not limited to, any applicable civil or criminal penalties. The DDS has the right to inspect and copy all records, files, reports, or any other materials deemed necessary to verify that the User has abided by all terms of the certificate unless such access is prohibited by law.
The burden of showing compliance with the provisions of this certificate is at all times on the User. Upon reasonable notice by the DDS, the User must be able to demonstrate such compliance. Users obtaining driving records for any of the aforementioned insurance purposes must have an application for insurance or renewal thereof in order to obtain driving records. Users obtaining driving records for employment or pre-employment background investigations must obtain the written consent of each licensee whose driving record is requested. Access granted to this User via the Requestor named above, if any, shall cease immediately the DDS terminated the Requestor s access to driving records for any reason. Termination, non-renewal, or expiration of the agreement between the Requestor named above and the Georgia Technology Authority terminates the User s access to driving records for any reason. The person signing below has authority to do so on behalf of the applicant named above. Date Title/Position Signature Printed Name
*HireRight, LLC. is required by the state DMV to keep this form signed and on file. STATE OF MICHIGAN - MOTOR VEHICLE RECORDS (MVRs) Insurance/Insurance Claims/Employment/Subscriber Certification Of Use I certify to the Michigan Department of State that abstracts of driving records obtained from HireRight, LLC. shall be used exclusively for the purposes of rating and qualifying drivers for insurance, insurance claims or employment I further certify that the company designated below, further agrees the information received will be used only in connection with the business purpose specified under this agreement. Additionally, designated company agrees that the information furnished under this agreement will not be used to engage in any illegal activity, or in any method, act, or practice, which is unfair or deceptive in the solicitation or advertisement of goods, services, or real estate to Michigan or other consumers. Designated company further agrees not to use the information furnished under this Agreement to compile other records for resale and to store, in any shape or form any record or data received from the Michigan Dept. Of State, any longer than permitted by law and to destroy or otherwise dispose of the data at the earliest time permitted by law. Company name (Address) Signature Printed Name & Title
*HireRight, LLC. is required by the state DMV to keep this form signed and on file. For Employers Only OHIO BUREAU OF MOTOR VEHICLES RECORD REQUEST (R.C. 149.43, 4501.15, 4501.27, AND 4507.53) PART A Please provide information regarding yourself: This agency is requesting disclosure of information that is NECESSARY to accomplish the statutory purpose as outlined under RC 4501.27. Disclosure of this information is REQUIRED. FAILURE to provide any information will result in this form not being processed. YOUR NAME (REQUESTER) JOB TITLE (IF APPLICABLE) STREET ADDRESS CITY x TELEPHONE NUMBER x BMV ACCOUNT NUMBER (IF APPLICABLE) x COMPANY (IF APPLICABLE) STATE FA NUMBER E-MAIL ZIP CODE PART B 1. I am requesting personal information contained in a motor vehicle record regarding one person: (Check one) driver abstract identification card record title record vehicle registration abstract other (describe) PERSON S NAME DATE OF BIRTH STREET ADDRESS CITY STATE ZIP CODE x SOCIAL SECURITY NUMBER DRIVER LICENSE NUMBER LICENSE PLATE NUMBER TITLE NUMBER VEHICLE IDENTIFICATION NUMBER 2. I am requesting personal information contained in a motor vehicle record regarding more than one person as follows: (describe) A record for use in the normal course of business by me as a legitimate business or an agent, employee, or contractor of a legitimate business, for one of the two following purposes: (a) to verify the accuracy of personal information submitted to the business, agent, employee, or contractor by an individual; A record or use by an employer or by the agent or insurer of an employer to obtain or verify information relating to the holder of a commercial driver license or permit that is required under the Commercial Motor Vehicle Safety Act of 1986, 100 Stat. 3207-170, 49 U.S.C. 2701, et seq., as now or hereafter amended; PART C 1. I (requester) qualify for release of personal information contained in a motor vehicle record because I am requesting an individual record, and I am not eligible under numbers 2 through 15 (on back). Signature Date
I (requester) qualify under number 2 through 16, as checked below, and I am requesting: 2. A record for use in the normal course of business by me as a legitimate business or an agent, employee, or contractor of a legitimate business, for one of the two following purposes: (a) to verify the accuracy of personal information submitted to the business, agent, employee, or contractor by an individual; (b) in case personal information submitted to the business, agent, employee, or contractor by an individual is incorrect or no longer correct, to obtain the correct information, for the sole purpose of preventing fraud, by pursuing legal remedies against, or recovering on a debt or security against, the individual. My tax identification number is: My vendor number is: My professional license number is: Licensed by (agency): 3. A record for use by a person, state, or state agency, and I HAVE ATTACHED THE WRITTEN CONSENT OF THE PERSON ABOUT WHOM THE PERSONAL INFORMATION IS SOUGHT; 4. Records for bulk distribution for surveys, marketing, or solicitations, where the information will be used, rented, or sold solely for bulk distribution for surveys, marketing, or solicitations; 5. A record for the use of a government agency, including, but not limited to, a court or law enforcement agency, in carrying out its functions, or for the use of a private person or entity acting on behalf of an agency of this state, another state, the United States, or a political subdivision of this state or another state in carrying out its functions; 6. A record for use in connection with matters regarding motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts, and dealers; motor vehicle market research activities, including, but not limited to, survey research; and removal of nonowner records from the original owner records of motor vehicle manufacturers; 7. A record for use in connection with a civil, criminal, administrative, or arbitral proceeding in a court or agency of this state, another state, the United States, or a political subdivision of this state or another state or before a self-regulatory body, including, but not limited to, use in connection with the service of process, investigation in anticipation of litigation, or the execution or enforcement of a judgment or order; (a subpoena or other court order may be used instead of this form); 8. A record pursuant to an order of a court of this state, another state, the United States, or a political subdivision of this state or another state; (a subpoena or other court order may be used instead of this form); 9. Records for use in research activities or in producing statistical reports, where the personal information will not be published redisclosed, or used to contact an individual; 10. Records for use by an insurer, insurance support organization, or self-insured entity, or by an agent, employee, or contractor of that type of entity, in connection with a claims investigation activity, anti-fraud activity, rating, or underwriting; 11 12. A record for use in providing notice to the owner of a towed, impounded, immobilized, or forfeited vehicle; A record for use by a licensed private investigative agency or licensed security service for any purpose permitted under numbers 1 through 15 of this form; my license number is: ; 13. A record or use by an employer or by the agent or insurer of an employer to obtain or verify information relating to the holder of a commercial driver license or permit that is required under the Commercial Motor Vehicle Safety Act of 1986, 100 Stat. 3207-170, 49 U.S.C. 2701, et seq., as now or hereafter amended; 14. 15. 16. A record for use in connection with the operation of a private toll transportation facility; A record for any other use specifically authorized by law that is related to the operation of a motor vehicle or to public safety; A record in order to carry out the purposes of either the Automobile Information Disclosure Act, 72 Stat. 325,15 U.S.C. 1231-1233, the Motor Vehicle Information and Cost Saving Act, 86 Stat. 947, 15 U.S.C. 1901, et seq., the National Traffic and Motor Vehicle Safety Act of 1966, 80 Stat. 718, 15 U.S.C. 1381, et seq., the Anti-Car Theft Act of 1992, 106 Stat. 3384, 15 U.S.C. 2021, et seq., or the Clean Air Act, 69 Stat. 322, 42 U.S.C. 7401, et seq., all as now or hereafter amended, for use in connection with one or more of the following matters: (a) motor vehicle or driver safety and theft; (b) motor vehicle emissions; (c) motor vehicle product alterations, recalls, or advisories; (d) performance monitoring of motor vehicles and dealers by motor vehicle manufacturers; (e) removal of non-owner records from the original owner records of motor vehicle manufacturers. I understand that if I receive personal information under number C 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, or 16 of this form, I may resell or redisclose the personal information only for uses permitted under numbers 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16. I understand that if I receive personal information under number C 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, or 16 of this form, and I resell or redisclose any personal information, I must keep for a period of five years a record that identifies each person or entity that receives any of the personal information and the permitted purpose for which the information is to be used, and I must make all such records available to the Registrar of Motor Vehicles upon his request. I HAVE VERIFIED ALL STATEMENTS ON THIS FORM BY SIGNING THIS FORM ON THE FRONT
Subscriber Certification of Use Use this form to certify the Subscriber s use of Washington State Department of Licensing data. Choose one: Insurance Company I hereby certify: 1. The insurance carrier to which the named individual has applied for motor vehicle insurance or life insurance and/or has life insurance in effect covering the named individual. 2. The insurance carrier or the agent of the insurance carrier designated below as Subscriber: a. Has motor vehicle insurance in effect covering the employer or a prospective employer; or b. Has motor vehicle insurance in effect covering the named individual; or c. Is the insurance carrier to which the employer or prospective employer has applied for motor vehicle insurance. 3. HireRight (company name) is acting as agent for Subscriber. 4. Abstract Driver Records shall be used exclusively for our insurance underwriting purposes only, and that no information contained therein shall be divulged, sold, assigned, or otherwise transferred to any third person or party. 5. The information contained in the abstracts of driver records obtained from the Department shall be used in accordance with the requirements and in no way violate the provisions of RCW 46.52.130, attached in part for easy reference. Employer / Transit authority / Volunteer organization I hereby certify: 1. The company or their agent designated below as Subscriber is an employer, prospective employer, a volunteer organization, or a transit authority for its vanpool program. 2. HireRight (company name) is acting as agent for Subscriber. 3. Abstracts of driver records shall be used exclusively for determining: a. Whether the volunteer licensee meets those insurance and risk management requirements necessary to drive a vanpool vehicle, or b. Whether an employee, prospective employee, or volunteer should be employed to operate a vehicle or for employment purposes related to driving by an individual as a condition of that individual s employment upon the public highways. 4. No information contained therein shall be divulged, sold, assigned, or otherwise transferred to any third person or party. 5. The information contained in the abstracts of driver records obtained from the Department shall be used in accordance with the requirements and in no way violate the provisions of RCW 46.52.130. The Subscriber listed below agrees to, and shall indemnify and hold harmless the state of Washington, Department of Licensing (DOL), the Director of DOL and all DOL employees from any and all suits at law or equity, and from any and all claims, demands or loss of any nature, including but not limited to all costs and attorney fees, arising from any incorrect or improper disclosure of individual names or addresses under this Subscriber Certification of Use; Any defects in any of Subscriber s procedures followed or omitted or arising from the failure of Subscriber or its officers, employees, customers, contractors or agents to fulfill any of its obligations under this Contract; or arising in any manner from any negligent act or omission by Subscriber or its officers, employees, customers, contractors or agents. I affirm that I am a representative authorized to bind the Subscriber named below. Subscriber name (Full company name) Address Authorized representative name (Print Name) Title Date and place signed Authorized representative signature CP-520-520 (N/2/13)E
RCW 46.52.130 7.24.2015 RCW 46.52.130: Abstract of driving record Access Fee Violations. Upon a proper request, the department may furnish an abstract of a person's driving record as permitted under this section. 1. Contents of abstract of driving record. An abstract of a person's driving record, whenever possible, must include: a. An enumeration of motor vehicle accidents in which the person was driving, including: i. The total number of vehicles involved; ii. Whether the vehicles were legally parked or moving; iii. Whether the vehicles were occupied at the time of the accident; and iv. Whether the accident resulted in a fatality; b. Any reported convictions, forfeitures of bail, or findings that an infraction was committed based upon a violation of any motor vehicle law; c. The status of the person's driving privilege in this state; and d. Any reports of failure to appear in response to a traffic citation or failure to respond to a notice of infraction served upon the named individual by an arresting officer. 2. Release of abstract of driving record. An abstract of a person's driving record may be furnished to the following persons or entities: a. Named individuals. i. An abstract of the full driving record maintained by the department may be furnished to the individual named in the abstract. ii. Nothing in this section prevents a court from providing a copy of the driver's abstract to the individual named in the abstract, provided that the named individual has a pending or open infraction or criminal case in that court. A pending case includes criminal cases that have not reached a disposition by plea, stipulation, trial, or amended charge. An open infraction or criminal case includes cases on probation, payment agreement or subject to, or in collections. Courts may charge a reasonable fee for the production and copying of the abstract for the individual. b. Employers or prospective employers. i. (A) An abstract of the full driving record maintained by the department may be furnished to an employer or prospective employer or an agent acting on behalf of an employer or prospective employer of the named individual for purposes related to driving by the individual as a condition of employment or otherwise at the direction of the employer. (B) Release of an abstract of the driving record of an employee or prospective employee requires a statement signed by: (I) The employee or prospective employee that authorizes the release of the record; and (II) the employer attesting that the information is necessary for employment purposes related to driving by the individual as a condition of employment or otherwise at the direction of the employer. If the employer or prospective employer authorizes an agent to obtain this information on their behalf, this must be noted in the statement. (C) Upon request of the person named in the abstract provided under this subsection, and upon that same person furnishing copies of court records ruling that the person was not at fault in a motor vehicle accident, the department must indicate on any abstract provided under this subsection that the person was not at fault in the motor vehicle accident. ii. In addition to the methods described in (b)(i) of this subsection, the director may enter into a contractual agreement with an employer or its agent for the purpose of reviewing the driving records of existing employees for changes to the record during specified periods of time. The department shall establish a fee for this service, which must be deposited in the highway safety fund. The fee for this service must be set at a level that will not result in a net revenue loss to the state. Any information provided under this subsection must be treated in the same manner and is subject to the same restrictions as driving record abstracts. c. Volunteer organizations. i. An abstract of the full driving record maintained by the department may be furnished to a volunteer organization or an agent for a volunteer organization for which the named individual has submitted an application for a position that would require driving by the individual at the direction of the volunteer organization. ii. Release of an abstract of the driving record of a prospective volunteer requires a statement signed by: (A) The prospective volunteer that authorizes the release of the record; and (B) the volunteer organization attesting that the information is necessary for purposes related to driving by the individual at the direction of the volunteer organization. If the volunteer organization authorizes an agent to obtain this information on their behalf, this must be noted in the statement. d. Transit authorities. An abstract of the full driving record maintained by the department may be furnished to an employee or agent of a transit authority checking prospective volunteer vanpool drivers for insurance and risk management needs. e. Insurance carriers. i. An abstract of the driving record maintained by the department covering the period of not more than the last three years may be furnished to an insurance company or its agent: (A) That has motor vehicle or life insurance in effect covering the named individual; (B) To which the named individual has applied; or (C) That has insurance in effect covering the employer or a prospective employer of the named individual. ii. The abstract provided to the insurance company must: (A) Not contain any information related to actions committed by law enforcement officers or firefighters, as both terms are defined in RCW 41.26.030, or by Washington state patrol officers, while driving official vehicles in the performance of their occupational duty. This does not apply to any situation where the vehicle was used in the commission of a misdemeanor or felony; (B) Include convictions under RCW
46.61.5249 and 46.61.525, except that the abstract must report the convictions only as negligent driving without reference to whether they are for first or second degree negligent driving; and (C) Exclude any deferred prosecution under RCW 10.05.060, except that if a person is removed from a deferred prosecution under RCW 10.05.090, the abstract must show the deferred prosecution as well as the removal. iii. Any policy of insurance may not be canceled, nonrenewed, denied, or have the rate increased on the basis of information regarding an accident included in the abstract of a driving record, unless the policyholder was determined to be at fault. iv. Any insurance company or its agent, for underwriting purposes relating to the operation of commercial motor vehicles, may not use any information contained in the abstract relative to any person's operation of motor vehicles while not engaged in such employment. Any insurance company or its agent, for underwriting purposes relating to the operation of noncommercial motor vehicles, may not use any information contained in the abstract relative to any person's operation of commercial motor vehicles. v. The director may enter into a contractual agreement with an insurance company or its agent for the limited purpose of reviewing the driving records of existing policyholders for changes to the record during specified periods of time. The department shall establish a fee for this service, which must be deposited in the highway safety fund. The fee for this service must be set at a level that will not result in a net revenue loss to the state. Any information provided under this subsection must be treated in the same manner and is subject to the same restrictions as driving record abstracts. f. Alcohol/drug assessment or treatment agencies. An abstract of the driving record maintained by the department covering the period of not more than the last five years may be furnished to an alcohol/drug assessment or treatment agency approved by the department of social and health services to which the named individual has applied or been assigned for evaluation or treatment, for purposes of assisting employees in making a determination as to what level of treatment, if any, is appropriate, except that the abstract must: i. Also include records of alcohol-related offenses, as defined in RCW 46.01.260(2), covering a period of not more than the last ten years; and ii. Indicate whether an alcohol-related offense was originally charged as a violation of either RCW 46.61.502 or 46.61.504. g. City attorneys and county prosecuting attorneys. An abstract of the full driving record maintained by the department, including whether a recorded violation is an alcohol-related offense, as defined in RCW 46.01.260(2), that was originally charged as a violation of either RCW 46.61.502 or 46.61.504, may be furnished to city attorneys or county prosecuting attorneys. City attorneys and county prosecuting attorneys may provide the driving record to alcohol/drug assessment or treatment agencies approved by the department of social and health services to which the named individual has applied or been assigned for evaluation or treatment. h. State colleges, universities, or agencies, or units of local government. An abstract of the full driving record maintained by the department may be furnished to (i) state colleges, universities, or agencies for employment and risk management purposes or (ii) units of local government authorized to self-insure under RCW 48.62.031 for employment and risk management purposes. i. Superintendent of public instruction. An abstract of the full driving record maintained by the department may be furnished to the superintendent of public instruction for review of public school bus driver records. The superintendent or superintendent's designee may discuss information on the driving record with an authorized representative of the employing school district for employment and risk management purposes. 3. Release to third parties prohibited. Any person or entity receiving an abstract of a person's driving record under subsection (2)(b) through (i) of this section shall use the abstract exclusively for his, her, or its own purposes or as otherwise expressly permitted under this section, and shall not divulge any information contained in the abstract to a third party. 4. Fee. The director shall collect a thirteen dollar fee for each abstract of a person's driving record furnished by the department. Fifty percent of the fee must be deposited in the highway safety fund, and fifty percent of the fee must be deposited according to RCW 46.68.038. 5. Violation. a. Any negligent violation of this section is a gross misdemeanor. b. Any intentional violation of this section is a class C felony. RCW 46.52.130 7.24.2015
Release of Interest Employer, prospective employer, or volunteer organization name: Company Name Agent business name if acting on behalf of the company for employment purposes: HireRight This is an authorization of: 1. Employee. for release of my driving record for employment purposes, at my employer s discretion for the full term of my employment; or 2. Prospective employee. for release of my driving record for employment purposes, not to exceed 30 days from date signed; or 3. Volunteer. for release of my driving record for a position applied for that requires me driving at the direction of the volunteer organization. I,, am an employee, prospective employee, or volunteer of the Your name (Print Name) company named above and I request DOL release a copy of my official driving record in the state of Washington to my employer, prospective employer, volunteer organization, or their agent. No employer, prospective employer, or their agent may use information contained in a driving record related to the sealed juvenile record of an employee or prospective employee for any purpose unless required by federal law. The employee or prospective employee must furnish a copy of the court order sealing the juvenile record to the employer, prospective employer, or their agent. Employee / Prospective employee / Volunteer full name (First, Middle, Last) (Print) Date of birth (mm/dd/yyyy) WA driver license number Employee / Prospective employee / Volunteer signature Date signed The company listed below agrees to, and shall indemnify and hold harmless the state of Washington, Department of Licensing (DOL), the DOL Director, and all DOL employees from any and all suits at law or equity, and from any and all claims, demands or loss of any nature, including but not limited to all costs and attorney s fees, arising from any incorrect or improper disclosure of individual names or addresses under this Release of Interest; any defects in any of Company s procedures followed or omitted or arising from the failure of Company or its officers, employees, customers, contractors or agents to fulfill any of its obligations under this contract; or arising in any manner from any negligent act or omission by the company or its officers, employees, customers, contractors, or agents. I hereby certify: 1. The company named below is an employer, prospective employer, or volunteer organization of the above-named individual. 2. The information contained in the driving record obtained from DOL shall be used in accordance with the requirements and in no way violate the provisions of RCW 46.52.130. No information contained therein will be divulged, sold, assigned, or otherwise transferred to any third person or party. The driving record shall be used exclusively for: Purpose I affirm that I am a representative authorized to bind the company named below. Company name (Legal Company Name) Authorized representative name (Print Name) Title Address Date and place signed Authorized representative signature NOTE: The employer or prospective employer must maintain this record for a period of not less than 3 years from the date of the request. Failure to obtain all signatures or misuse of records obtained from the state of Washington may result in prosecution under RCW 46.52.130. We are committed to providing equal access to our services. DSC-425-020 (R/10/15)E If you need accommodation, please call (360) 902-3708 or TTY (360) 664-0116.
DL9105 (1013) Account Number: EMPLOYMENT AFFIDAVIT OF INTENDED USE INFORMATION SALES UNIT (See Reverse Side for Instructions) Business Type (check one): Individual Partnership Corporation Non-Profit Legal Business Name: D/B/A Name (if applicable): Person Responsible: Name: Title: Physical Address: City: State: Zip: Business Telephone: Fax No.: Email: Website Address: Federal Employer ID No.: If Corporation, Date & State of Incorporation: Year Business Established: Dun & Bradstreet #: U.S. DOT #: (if applicable) Location of Records: For departmental onsite inspection, audit and review purposes. Check here, If address is same as above. Street Address: City: State: Zip: Type of Business: Ownership: List below individual, each partner, or each corporate officer participating in the direction, control or management of the business. Attach list if needed. Name (Last, First, MI) Title Date of Birth (MM/DD/YYYY) 1. 2. Driver License STATE Day-Time Phone Number 3. 1. 2. 3. 4. 5. 6. 7. 8. 9. Please initial each statement below and sign at the bottom of the form. I swear and affirm that any requested information will be used for employment purposes only. I swear and affirm that I have on file a signed release for the subject of each driver record requested. I swear and affirm that I understand the driver records is confidential and restricted information and I will establish procedures to protect the confidentiality of these records. I swear and affirm that I will not request driver information from the Department for personal reasons. (Examples of inappropriate access or misuse of Department information included, but not limited to: making personal inquiries on my own record or those of my relatives; accessing information about another person, including locating their residence address, for any reason that is not related to my job responsibilities.). I swear and affirm that the information obtained from the Department shall not be sold, assigned or otherwise transferred to any other party. I swear and affirm that I understand that the Department retains exclusive ownership of all driver record information provided and no record shall be combined and/or linked in with any other data on any database for any reason. I swear and affirm that the information obtained from the Department will not be used for direct mail advertising or any other type or types of mail and mailings. I swear and affirm that I will not disseminate or publish on the Internet the personal information obtained from the Department or allow any other person to disseminate or publish the personal information on the Internet without the express written permission of the Department. I swear and affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this form is subject to the penalties of 18 PA C.S. Section 4903(a)(2) (relating to false swearing), which shall include punishment of the fine not exceeding $5,000, or a term of imprisonment of not more than two years, or both. Subscribed and Sworn to Before Me: Mo. Day Year S Signature of Person Administering Oath Signature Date E A L Sign in Presence of Notary Title
INSTRUCTIONS FOR COMPLETING THE AFFIDAVIT OF INTENDED USE 1. The affidavit must be completed and signed by a member of your agency or firm who has the authority to certify the agency or firm s compliance. 2. Please complete each line on the form in its entirety to avoid delays in processing your affidavit. If requested information does not apply to your business insert n/a(not-applicable) on that line 3. The person responsible for completing the affidavit must initial each of the nine (9) declaration statements, then sign and date the form in the presence of a Notary. 4. This affidavit must be returned to your information provider. 5. You are required to complete, notarize and file a new Affidavit of Intended Use whenever information about your company changes. (name, address, ownership, telephone, website, etc.) 6. If you need assistance in completing this affidavit, please contact your information provider.