Premium Service Subscription Agreement

Virginia.gov

INFORMATION USE APPLICATION
For Electronic Access to Virginia Department of Motor Vehicle Records

THIS APPLICATION IS FOR ELECTRONIC ACCESS TO VIRGINIA DEPARTMENTOF MOTOR VEHICLES (DMV) DRIVER AND VEHICLE RECORDS ONLY.CONTACT DMV DIRECTLY FOR ALL OTHER TYPES OF ACCESS TO DMVRECORDS.

INSTRUCTIONS:

1. Use an ink pen or typewriter to complete the application.
2. Complete all applicable sections of the application. Be as specific as possible. If additional room is needed, attach additional pages. Please write N/A beside any section(s) or question(s) that do not apply to the applicant.
3. Have an authorized agent or representative of the applicant sign and date the application.
4. Mail complete applications and all supporting documents to: Virginia Interactive (VI) 1111 East Main Street, Suite 901 Richmond, Virginia 23219
5. Unsigned or incomplete applications cannot be processed and will be returned to the applicant.
6. Applications with false, misleading, or otherwise deceptive information will not be processed and may be grounds for criminal prosecution.
7. A VI premium service subscription agreement must be completed and submitted along with the information use application.

SPECIAL APPLICATION NOTES AND PROVISIONS

- DMV IS CUSTODIAN OF DRIVER AND VEHICLE RECORDS FOR THE COMMONWEALTH OF VIRGINIA. PURSANT TO AN AGREEMENT BETWEEN DMV AND VIRGINIA INTERACTIVE (VI), DMV HAS AUTHORIZED VI TO PROVIDE AUTHORIZED USERS ELECTRONIC ACCESS TO DMV RECORDS.

- EACH APPROVED APPLICANT MUST EXECUTE WITH VI AN INFORMATION USEAGREEMENT THAT SPECIFIES THE REQUIREMENTS FOR AND RESTRICTIONS ONELECTRONIC ACCESS TO DMV RECORDS.

- THIS APPLICATION IS SUBJECT TO AMENDMENT BASED ON CHANGES IN STATE ORFEDERAL LAWS, RULES, AND REGULATIONS GOVERNING ACCESS AND USE OF DMVRECORDS.

- BY SUBMITTING THIS APPLICATION, THE APPLICANT AGREES TO ABIDE BY ALL LAWS, RULES, AND REGULATIONS GOVERNING THE USE AND DISSEMINATION OF INFORMATION CONTAINED INDMV RECORDS. THE APPLICANT SHOULD BEFAMILIAR WITH: SECTIONS 2.1-377 THROUGH 2.1-386 AND 46.2-208 THROUGH 46.2-209 OF THE CODE OF VIRGINIA, THE FEDERAL FAIR CREDIT REPORTING ACT, PUBLICLAW 91-508, AND SECTION 2721 OF THE FEDERAL DRIVER?S PRIVACY PROTECTION ACT OF 1994, PUBLIC LAW NUMBER 103-322.

- VIOLATION OF THE STATE LAWS CONCERNING USE OF DMV RECORDS IS PUNISHABLE AS A CLASS 4 MISDEMEANOR; VIOLATION OF FEDERAL PUBLIC LAW 91-508 IS PUNISHABLE BY UP TO A $5,000 FINE OR ONE YEAR IMPRISONMENT OR BOTH.

- IF APPROVED FOR ELECTRONIC ACCESS TO DMV RECORDS, APPLICANT WILL BESUBJECT TO REASONABLE INSPECTION AND/OR AUDIT TO ENSURE COMPLIANCEWITH THE TERMS AND PROVISIONS CONTAINED IN THE INFORMATION USEAGREEMENT EXECUTED WITH VI.

- THERE IS A $7.00 FEE FOR EACH DMV RECORD REQUESTED. VI MUST RECEIVEPAYMENT FOR RECORD REQUESTS BY THE 25TH OF EACH MONTH. PLEASE SPECIFYYOUR PREFERRED BILLING METHOD IN THE VI PREMIUM SERVICESUBSCRIPTION AGREEMENT.

INFORMATION USE APPLICATION

The information below is required by the State Comptroller for debt set-off collection purposes inaccordance with Code of Virginia Section 2.1-196.1, 2.1-731, and 2.1-734

Please print or type.

PART 1: USER/COMPANY INFORMATION

User/Company Name: _____________________________________
Type of Business: ___________________________________
Social Security or Federal Identification Number: ______________________________
Address (Street or P.O. Box): ___________________________
City, State, Zip Code: _____________________________
Telephone Number: ____________________________
Facsimile Number: __________________________
E-mail Address: ___________________________
Request Date: _________________________

PART 2: TYPE OF INFORMATION REQUESTED

Please give a detailed description of the information that applicant is requesting (attach additional pages if necessary).

_________________________________________________________________

PART 3: STATED PURPOSE FOR REQUESTED INFORMATION

Please give a detailed description of the purpose(s) for applicant's access to the requested information (attach additional pages if necessary).

____________________________________________________________

PART 4: INFORMATION DELIVERY METHOD

CHECK ALL BLOCKS THAT INDICATE HOW YOU WISH TO RECEIVE REQUESTED INFORMATION

___ Request and receive information via electronic file transfer over the INTERNET

___Request and receive information via a Web-based interactive service over the INTERNET

PART 5: USER LIST

Please provide a list of all potential electronic access users and a description of the type access needed to obtain information (you may attach the list of names to the application).

Please advise if you currently use, or plan to use, a third party information service (provide name of information service below).

Name of Information System Contact Person: __________________________

Address (if different than applicant?s address):_______________________

Contact Person's Title: _________________________

Telephone Number:_________________

PART 6: INFORMATION SECURITY
Attach a copy of a plan outlining the steps or methods the applicant will take to secure and protect theinformation requested in this application. Please be as thorough as possible.

Address the following issues:

-Security of files and/or copies of records
-Security of online computer terminals
-Security of VI-issued token security devices
-Designation of authorized users/assignment of access codes
-Proposed audit/management controls over access and dissemination of requested information

PART 7: VALIDATION OF USER NEED
Attach a copy of any documents supporting the applicant's need for the requested information and verifying the identity of the applicant.

-Examples may include copies of the following:
-Business license or professional license
-Company charter, annual report, or financial statement
-Statement on company letterhead from the applicant user
-Other items validating the applicant?s need explained in part 3 of the application

PART 8: CERTIFICATION

I, the undersigned, hereby certify that: 1) all information contained herein is true; 2) I am a duly authorized agent of the above applicant; and 3) I am authorized to make application to VI for an information use agreement for the purposes stated in this application

User/Company Name (print or type):_______________________________

Request Date: User/Company Representative's name (print or type) _______________________

Address (if different than in part 1):_______________________________

User/Company Representative's Title (print or type):_________________________

User/Company Representative's Signature:_________________________

User/Company Representative's: ________________________

Telephone Number: ___________________

VI USE ONLY APPLICATION

Signature/Title/Date_______________________

__Approved

If Approved, list date Use Agreement mailed: ___________________

__Denied

If denied, give reason(s):______________________

Revised 06-30-05