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 VehiclesQuestions? 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 1106EApplication Commercial Requester Account (End User) *Fee: $50 (no residence address) OR

2 INF 1108Commercial Requester Account Agreement $250 (for residence address) AND

1 INF 1132Information 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 1106VApplication Commercial Requester Account (Vendor) *Fee: $250 application fee

2 INF 1108Commercial Requester Account Agreement $50,000 Surety Bond (for

1 INF 1132Information 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 1106AApplication Commercial Requester Account (Agent) *Fee: $250 application fee

2 INF 1108Commercial Requester Account Agreement $50,000 Surety Bond (for

2 INF 02Agent Addendum residence address)

2 INF 03Agent Authorization

1 INF 1132Information 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 1110Representative 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 1128Employee 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 1213Commercial 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 1184Certification 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 1106BLRequester 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

PART A: Main Office / DMV USE ONLY
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

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

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

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

NAME (LAST, FIRST, MI) TITLE DL/ID NUMBER AND STATE ISSUED

PART C: Licensing and Business Identification

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

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