REQUEST FOR INFORMATION - oregon.gov

1 ODL:DOB: Name:Address:City:State:Zip Code:735-7122 2 6)(Continued on next )STK# 300063 SECTION B. - I AM REQUESTING (For multiple inquires attach a separate sheet of paper with the below INFORMATION listed.)INSTRUCTIONS:DEPARTMENT OF TRANSPORTATIONDRIVER AND MOTOR VEHICLE SERVICES1905 LANA AVE NE, SALEM oregon 97314 DMVREQUEST FOR INFORMATIONU nder oregon law, only certain requestors qualify to receive personal INFORMATION from DMV recordsand these requestors can only use the INFORMATION for specific purposes outlined in oregon s RecordPrivacy Law (ORS ). If INFORMATION is protected, it will not be released unless arequestor qualifies to receive the INFORMATION . As defined in oregon s Record Privacy Law, personalinformation means the following INFORMATION that identifies an individual:PRIVACY RULES & REGULATIONSACCESS TO DMV RECORDS IS HIGHLY RESTRICTED.

2 IF YOU KNOWINGLY OBTAIN OR USEPERSONAL INFORMATION IN VIOLATION OF ORS ORS FROM A MOTORVEHICLE RECORD, YOU MAY BE SUBJECT TO CRIMINAL PROSECUTION OR A have read and understand the INFORMATION stated above and I understand I may be subject tocriminal and civil penalties if I misuse personal INFORMATION from oregon DMV License, Driver Permit or Identification Card NumberNameAddressTelephone Number REQUESTOR S SIGNATUREREQUESTOR S PRINTED NAMEDATEXNAME OF INDIVIDUAL, FIRM OR TRADE NAMEFAX NUMBERMAILING ADDRESSSTATEZIP CODE SECTION A. - REQUESTOR INFORMATIONS ection A. Section B. Section C. Section D. Section E. Fill out the name and address fields in must include enough vehicle and/or driver INFORMATION for DMV to locatethe record. List the type of record you are clearly how you intend to utilize DMV records(s).Check the box next to the type of entity, provide required documentation, andsign the bottom of the next TELEPHONE # (INCLUDE EXT.)

3 IF ANY)( )CITYV ehicle InformationDriver InformationPlate number:VIN: Year: Make:Model:E-MAIL ADDRESS(Continued on next ) SECTION C. - TYPE OF RECORD REQUESTED 735-7122 (2- 6)Will personal INFORMATION be provided to others?Explain in detail how you intend to use oregon DMV records:_____ 2)1)NOYESWho in your business will have access to oregon DMV records?4)_____How will you ensure oregon DMV records are not accessed by unauthorized parties?3)_____If "YES," to whom and for what reason?_____ If "YES," how? BY INTERNET BY TELEPHONE BY FAX *See Form 735-6691 DMV Record Fee List for additional records and for police reports regarding automobile accidents REQUIRE the following INFORMATION inaddition to the driver INFORMATION in Section of Accident: _____ , County (or nearest city if county unknown): _____DMV cannot locate the report by the police report number, if the above INFORMATION is not providedyour REQUEST will not be processed and returned back to you.

4 SECTION D. - EXPLAIN HOW DMV RECORD(S) WILL BE UTILIZED NON-EMPLOYMENT DRIVING RECORD = 3 YEAR RECORD $ DRIVING RECORD = 3 YEAR RECORD $ LICENSE INFORMATION $ NON-EMPLOYMENT DRIVING RECORD $ COURT PRINT = THIS OPTION MAY INCLUDECPMORE THAN FIVE YEARS OF RECORD INFORMATION $ RECORD PRINT $ TITLE HISTORY $ OWNER INFORMATION $ INFORMATION SEARCH $ $ :_____CERTIFIED COURT PRINT with CDL MEDICAL CERTIFICATIONINFORMATION = MAY INCLUDE MORE THAN FIVE YEARS OF RECORD INFORMATION $ M4(Continued on next )Process Server - Submit copies of the documents or materials you are serving and proof that you are over 18 yearsold ( ; copy of your driver license, birth certificate, etc). I certify that I am a process server authorized under ORS (4)(b) to obtain personal INFORMATION from DMV motorvehicle records. Personal INFORMATION I obtain will be used solely in connection with an existing civil, criminal,administrative or arbitration proceeding, or a judgment in any court, government agency or self-regulatory certify that I am a licensed oregon 0rivate )nvestigator authorized under ORS (18) to obtain personalinformation from DMV motor vehicle records.

5 Personal INFORMATION I obtain will be used for one or more of thepurposes outlined in ORS Investigator - Submit your license number _____ issued by the oregon Department ofPublic Safety Standards & Agency - Submit your business card and your Federal Employer ID Number _____ .I certify that I am a government agency authorized under ORS (1) to obtain personal INFORMATION from DMVmotor vehicle records. Personal INFORMATION I obtain will be used solely for carrying out this government agency sgovernmental Institution - Submit a copy of your membership charter or your FDIC or NCUA insurance certificate. I certify that I am an attorney, collection agency, or financial institution authorized under ORS (4) to obtainpersonal INFORMATION from DMV motor vehicle records. Personal INFORMATION I obtain will be used solely in connectionwith serving a civil, criminal, administrative or arbitration proceeding in a court, government agency, or Agency - Submit a copy of your current registration certificate issued by the oregon Department ofConsumer and Business Services.

6 Attorney - If you are a member of the oregon State Bar, submit your bar number _____ . If you are alicensed attorney in a state other than oregon , submit your state bar number _____ and copies ofdocuments that prove you are a licensed attorney by the state in which you practice Business - Submit one of the following: s A Business License. s A Certificate of Existence orAuthorization issued by the Secretary of State; s A current copy of a Business Partnership Agreement; s A copy of thebusiness income tax form filed for the latest tax period for which filing was required; s A certification from the Office ofMinority, Women, and Emerging Small at least two of the following: s ! BUSINESS INVOICE ISSUED BY THE BUSINESS WITHIN THE LAST THREE MONTHS s ! CURREN tbusiness card; s A copy of a signed contract for work performed within the last six months; s A copy of a current rental,lease or purchase agreement or proof of ownership of the business premises; s A copy of a current rental or leaseagreement or receipt of purchase for business equipment; s A copy of a business related loan agreement; s A copy ofa current business or Self-Insured Entity - Submit a copy of your current Certificate of Authority issued by the Insurance Division;or submit a copy of your current Insurance License issued by the Insurance Division.

7 Or submit a copy of theself-insured employer s certificate provided by the Department of Consumer and Business Services or similarcertification as required by the state in which the employer is certify I am an Insurer, Self-Insured Entity, or Insurance Support Organization authorized under ORS (6) toobtain personal INFORMATION from DMV motor vehicle records. Personal INFORMATION I obtain will be used solely inconnection with claims investigation activities, anti-fraud activities, underwriting, or certify that I am a legitimate business authorized under ORS (3) to obtain personal INFORMATION from DMVmotor vehicle records. Personal INFORMATION I obtain will be used solely in the normal course of business for: A. Verifying the accuracy of personal INFORMATION submitted to the business: or B. Correcting personal INFORMATION submitted to the business, but only in order fraud; legal remedies against the individual who submitted the personal INFORMATION ; a debt from, or satisfy a security interest against, the : You may not act as a third party to provide INFORMATION to others.

8 You must be the end user of the INFORMATION . SECTION E. - ENTITY TYPE (Check the box next to the entity you are requesting INFORMATION under and certifying to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or more INFORMATION see our website at: or send an email to: the completed form with requestor ssignature, required documentation, and fee to:(A check or money order payable to oregon DMV.)

9 For a list of DMV record types and fees, see Form Record Services1905 Lana Avenue NESalem, OR 97314-2250 SECTION E. - INTENDED USE (Continued from previous page.)I certify:s 4HE RECORD INFORMATION ) OBTAIN FROM $-6 WILL BE USED ONLY FOR THE PURPOSES STATED UNDER THE ENTITY ) HAVE SELECTED s I understand that I may not act as a third party on behalf of any other business or individual to obtain personal ) UNDERSTAND THAT ) WILL ONLY RESELL OR REDISCLOSE PERSONAL INFORMATION OBTAINED FROM $-6 AS AUTHORIZED BY /23 )F YOU DO NOT COMPLY WITH THIS REQUIREMENT AND YOU RESELL OR REDISCLOSE PERSONAL INFORMATION TO SOMEONE WHO HAS NOT BEEN AUTHORIZED BY $-6 TO RECEIVE IT FUTURE REQUESTS FOR RECORDS WILL BE DENIED AND YOU BY BE SUBJECT TO CIVIL AND criminal penalties. s ) UNDERSTAND THAT IF ) KNOWINGLY OBTAIN OR USE PERSONAL INFORMATION IN VIOLATION OF /23 /23 ) MAY BE SUBJECT TO CRIMINAL PROSECUTION OR A CIVIL ACTION Tow Company - List an oregon TW plate number _____ for a currently registered tow vehicle thatis titled in the same name as the certify that I am a tow company authorized under ORS (7) to obtain personal INFORMATION from DMV motorvehicle records.

10 Personal INFORMATION I obtain will be used solely to give notice to another person concerning thevehicle when required by the state or federal Constitution, a statute, or an )'.!452% /F 2%Q5%34O24)4,% O& 2%15%34O2DA4%XFor out of state companies, submit a copy of a registration from one of your vehicles that has your company name onit. 2 6 I certify I am am a representative of the news media authorized under ORS (14) to obtain personal informationfrom DMV motor vehicles records. Personal INFORMATION I obtain will be used solely for the gathering or dissemination ofinformation related to the operation of a motor vehicle or to public Support Organization - Required Proof:A.) An attachment describing the types of services you provide (anadvertising brochure for example) to prove that you are a lien support organization;ANDB.) A copy of the form orpermission slip that your customers sign authorizing you to act on their behalf in order to give notice concerning avehicle;AND C.