A Public Service Agency INFORMATION SERVICES PROGRAM GOVERNMENT REQUESTER ACCOUNT APPLICATION PART I APPLICATION PleASe PRInT CleARly In Ink OR TyPe DMV USe Only RequesteR Code expiRation date teCh id SECTION A. TYPE OF APPLICATION CheCk One (1) BOX Only: Original — Complete ALL SECTIONS — DMV will assign Requester/Parking/Court Code. Change(s) to Existing Account — Complete Sections A, B and C, and all applicable sections where information is changing. Provide signature in Part II, Section F. Provide current Requester/Parking/Court Code(s): __________________________________________ Renewal — Complete ALL SECTIONS — Provide current Requester/Parking/Court Code(s): _______________________________ IMPORTAnT: TO AVOID PROCESSING DELAYS, PLEASE READ ALL INSTRUCTIONS PRIOR TO COMPLETING FORM. SECTION B. AGENCY INFORMATION 1. NAME OF AGENCY 2. DIVISION/PROGRAM THAT WILL REQUEST DEPARTMENT INFORMATION 3. AGENCY WEBSITE ADDRESS OR INDICATE “NONE” 4. FAX NUMBER 5. NAME AND TITLE OF THE PERSON FOR DMV CONTACT 6. TELEPHONE ( 8. STREET ADDRESS (PHYSICAL LOCATION) STREET CITY 7. E-MAIL ADDRESS ) COUNTY 9. MAILING ADDRESS OR INDICATE “SAME” STATE ZIP 10. RECORD STORAGE PHYSICAL ADDRESS SECTION C. TYPE OF AGENCY 1. CHECK APPROPRIATE BOX FOR THE TYPE OF GOVERNMENT AGENCY (CheCk Only One): Federal State City County Special District Other: _____________________________________________ DESCRIBE 2. IS THIS ACCOUNT BEING ESTABLISHED BY A GOVERNMENT ENTITY EXCLUSIVELY FOR USE BY ONE OF THE FOLLOWING? Yes, check appropriate box. No, go to Section D. CALIFORNIA APPLICANTS “Peace Officers” as described in California Penal Code §830.1 through 830.5. Identify Section #: _______________________________ City Attorney prosecuting misdemeanor actions under Government Code Section 41803.5. ANY STATE OR FEDERAL APPLICANT Attorney General District Attorney Public Defender Public Defender’s Investigator Government employees having statutory authority to carry firearms AND execute warrants AND make arrests. Identify Statutory Authority; Code and Section #: ___________________________________________________________________________________ SECTION D. PURPOSE OF ACCOUNT — Check one purpose only (Continued on Page 2) 1. 2. EPN (Employer Pull Notice) – Check this box if you are enrolling employees in the EPN program. For more information about the EPN program and to obtain enrollment forms, go to www.dmv.ca.gov and “Search” for EPN General Information. UPDATE AND INQUIRY – If your Agency is applying for authorization to update DMV records (i.e., courts, parking/toll, revenue recovery, etc.), check this box. Explain the purpose of updating DMV records (space provided below): a. DMV USe Only Purpose Approved? Yes No Vehicle/Vessel Registration (VR) PURPOSE OF UPDATE: b. DMV USe Only Purpose Approved? Yes No Driver License/Identification Card (DL) PURPOSE OF UPDATE: INF 1130 (REV. 10/2013) WWW 1 of 4 Go to Page 2 SECTION D. PURPOSE OF ACCOUNT (Continued from Page 1) 3. INQUIRY ONLY – If your Agency is applying for authorization to request and obtain DMV record information in order to carry out your governmental functions, check this box. Explain the purpose of inquiry below: a. DMV USe Only Purpose Approved? Yes No Vehicle/Vessel Registration (VR) PURPOSE OF INQUIRY: Is residence address necessary to perform this function? b. Yes No DMV USe Only Purpose Approved? Yes No Driver License/Identification Card (DL/ID) PURPOSE OF INQUIRY: Is residence address necessary to perform this function? c. Yes No DMV USe Only Purpose Approved? Yes No Financial Responsibility (FR) - Available in paper/hardcopy only — See Instructions for more information. PURPOSE OF INQUIRY: Is residence address necessary to perform this function? d. Yes No DMV USe Only Purpose Approved? Yes No Occupational License (OL) PURPOSE OF INQUIRY: Is residence address necessary to perform this function? SECTION E. Yes No ACCESS METHOD(S) — Check All That Apply Paper/Hardcopy - Manual Process (Allow 7 to 14 working days) Cartridge Tape (IBM Compatible, 3480 non-compressed or 3490 compressed) - Batch (Overnight plus mail time) - Renewals Only File Transfer Protocol (FTP) via Virtual Private Network (VPN) - Batch (Overnight) On-Line - (Requires Network Connection) COMPLETE SECTION F. CLETS - If you are applying for a requester code in order to obtain access through the CA Law Enforcement Telecommunications System (CLETS), check this box. SECTION F. 1 ON-LINE APPLICANTS ONLY — DO nOT COMPleTe FOR CleTS ACCeSS HOURS OF ON-LINE ACCESS: Days __________________________________________ 2. 3. Hours _____________________ A.M. TO ____________________ P.M. NAME OF DATA CENTER (I.E., DTS OR CITY/COUNTY DATA CENTER, etc.) TELEPHONE # DATA CENTER WEBSITE ADDRESS NAME AND TITLE OF THE DATA CENTER TECHNICAL COORDINATOR TELEPHONE #. E-MAIL ADDRESS STREET ADDRESS (PHYSICAL LOCATION) CITY COUNTY STATE ZIP CODE MAILING ADDRESS (IF DIFFERENT) CITY COUNTY STATE ZIP CODE NAME AND TITLE OF INFORMATION SECURITY OFFICER TELEPHONE # E-MAIL ADDRESS NAME AND TITLE OF ACCESS CONTROL ADMINISTRATOR TELEPHONE # E-MAIL ADDRESS STREET ADDRESS (PHYSICAL LOCATION) CITY COUNTY STATE ZIP CODE MAILING ADDRESS (IF DIFFERENT) CITY COUNTY STATE ZIP CODE 2 of 4 Go to Page 3 INF 1130 (REV. 10/2013) WWW PART II AGREEMENT – PleASe ReAD eACh SeCTIOn CAReFUlly A. GENERAL PROVISIONS 1. This Application/Agreement, hereinafter referred to as “Agreement”, is between the State of California, Department of Motor Vehicles (DMV), hereinafter referred to as the “Department”, and the Government Agency identified in Part I, hereinafter referred to as the “Requester”, for the purpose of the Department providing information from its files for Government Agency use. 2. The term of this Agreement shall be for forty eight (48) months from the approval date and renewable at forty eight (48) month intervals thereafter. 3. 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), California Code of Regulations (CCR) Title 13, and United States Code Title 18. 4. No alteration or variation of the terms of this Agreement shall be valid unless made in writing and signed by both parties hereto. No oral understanding or agreement, not incorporated herein, shall be binding on either party. 5. Requester shall not represent themselves as agents/employees of the Department. For the purposes of this Agreement, the “Requester” includes the Requester’s employees, unless the context provides otherwise. 6. (Applies to Federal Government and Out-of-State Agencies/Requesters)—“The Requester agrees to pay for any loss, liability or expense, including attorney fees, expert witness fees and court costs, which arises out of or relates to the Requester’s acts or omissions regarding its obligations hereunder, where a final determination of liability on the part of the Requester is established by a court of law or where settlement has been agreed to by the Requester. This provision may not be construed to limit the Requester’s rights, claims, or defenses which arise as a matter of law or under any other provision of this Agreement. This provision may not be construed to limit the sovereign immunity of the Requester.” 7. This Agreement is not assignable by the Requester, either in whole or in part, without prior written consent of the Department. 8a. Any promotional or informational material related to accessing the Department’s records shall be accurate and consistent with the terms of this Agreement and shall only contain factual statements relating to the purpose and condition of access. b. Requester shall not use the logogram in any advertising or other agency business materials used in the business of the Requester. Advertising shall neither state nor imply that there is any official connection between the Department and the Requester, or that the Department has sanctioned or approved of either the advertisement or the Requester’s service. 9a. If the Authorized Representative, designee responsible for the administration of the account, the DMV contact person, agency address, or any other changes of information occur in Part I of this Agreement, notification shall be submitted, in writing, within ten (10) business days on Government Requester Account Application (INF 1130) or Agency Letterhead to the following address: Department of Motor Vehicles, Account Processing Unit—H221, P.O. Box 944231, Sacramento, CA 94244-2310 b. Requester shall notify the Account Processing Unit, in writing, (see address in 9a) within ten (10) business days of any intended or actual closure of the Government Agency Requester Account. B. INFORMATION USE 1. Requester shall not use Department records for any purpose except for that which has been approved by the Department in Part I. 2. When a non-law enforcement agency receives information from Department records that indicates a vehicle or vessel has a Department of Justice (DOJ) “stop”, Requester shall immediately notify local law enforcement of its location, if known. C. GENERAL SECURITY REQUIREMENTS 1. Requester shall maintain the security and integrity of the information it receives. A violation of any provision(s) of the Agreement, whether by omission or commission, may result in suspension or termination of service to Requester. 2. Requester shall ensure compliance with all the security provisions of this Agreement. If misuse or inappropriate access is suspected or confirmed, Requester shall notify the Department’s Information Services Branch, Policy and Information Privacy Section, by telephone, at (916) 657-5583 within one (1) business day. A written notification containing all facts therein shall be prepared by the Requester within three (3) business days and mailed to the Department at the following address: Department of Motor Vehicles, Information Services Branch, Policy and Information Privacy Section—H225, P. O. Box 942890, Sacramento, CA 94290-0890 3. In the event of any breach of the security of the Requester’s system or database containing the personal information of California residents, the Requester shall bear all responsibility for providing notice of the breach to the affected residents as required by California Civil Code Section 1798.29. The Requester shall bear all costs associated with providing this notice. In addition, the Requester agrees to comply with all federal and California state law, including all of the provisions of the California statutes and Title 13 of the California Code of Regulations. 4a. Requester shall require every employee and the system administrator having direct or incidental access to Department records to sign a copy of the Information Security Statement (INF 1128). The INF 1128 is required upon initial authorization for access to Department records and annually thereafter. The Requester’s signed statement(s) shall be maintained on file at Requester’s work site for at least two years following the deactivation or termination of the authorization and shall be available to the Department upon demand. b. Requester shall restrict the use and knowledge of requester codes and operational manuals to employees who have signed an Information Security Statement (INF 1128). c. Requester shall maintain a current list of names of persons authorized to access Department records. This list shall be available to the Department upon demand. 5. 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 are placed in a locked room that is not accessible to unauthorized persons. 6. Video terminals, printers, hardcopy printouts, or any other form of duplication of Department approved records that are located in public access areas shall be placed so that the records shall not be viewed by the public or other unauthorized persons. INF 1130 (REV. 10/2013) WWW 3 of 4 Go to Page 4 7. All information received from the Department’s files must be destroyed once its legitimate use has ended. The method of destruction for the Department’s records will be conducive to the type of record requested and in a manner that cannot be reproduced or identified in any physical or electronic form. 8. Requester shall not disclose its’ Department assigned requester code, either orally or in writing, to anyone who is not in the direct employ of the Requester and has not signed the Information Security Statement (INF 1128) other than a Department approved Service Provider (Vendor or Agent). 9. Requester 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 Department. D. RESIDENCE ADDRESS ACCESS AUTHORITY 1. Requester shall protect the confidentiality of any residence address received from Department records pursuant to CVC §1808.47. Requester’s employees shall not obtain or use any confidential or restricted records for any purpose other than the reason set forth and authorized by the Department. 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 an agreement acknowledging the confidentiality of residence address information pursuant to CVC §1808.47 is signed by the individual with whom the Requester has contracted services. E. AUDIT 1. Requester’s documentation supporting the reason for inquiry, including but not limited to, transaction details, and computer software/ programs maintained for the purposes defined in this Agreement, shall be subject to inspection, review, or audit by the Department or its designee for a period of two years from the date of the request. 2. Requester agrees to accommodate Department’s request for an inspection, review or audit immediately upon request from the department or the department’s representative and to allow on-site audits during regular business hours. F. SIGNATURE REQUIREMENTS I hereby acknowledge that I am an authorized representative of the agency named in Part I, Section B and have been designated as the person responsible for compliance with the statutes and regulations pertaining to access and use of Department record information. I have read and agree to the provisions contained herein and shall be responsible for the orientation, training, and supervision of persons authorized to access Department record information. I understand that false or misleading answers are cause for denial of an Agreement and/or termination of any access agreement granted. I understand that if this application for requester account is approved, I will be required to conform to the statements presented within. This Agreement specifies the terms and conditions of our relationship. Any deviations will be considered by DMV 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 use of any false report to obtain information from any department record, 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 up to five (5) years or revoked. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. PRINT NAME AND TITLE OF GOVERNMENT OFFICIAL OR AUTHORIZED REPRESENTATIVE DAYTIME TELEPHONE NUMBER ( SIGNATURE OF GOVERNMENT OFFICIAL OR AUTHORIZED REPRESENTATIVE CITY COUNTY STATE ) DATE X APPROVED BY DEPARTMENT OF MOTOR VEHICLES REPRESENTATIVE: PRINT NAME AND TITLE DATE SIGNATURE X WheRe TO MAIl yOUR APPlICATIOn AnD SUPPORTInG DOCUMenTS ALL AGENCIES (Except Parking/Toll Agencies) PARKING AND TOLL AGENCIES ONLY, mail to: mail to: Department of Motor Vehicles Department of Motor Vehicles Account Processing Unit – MS H221 Justice & Government Liaison Branch PO Box 944231 Attn: Parking Coordinator – MS H171 Sacramento, CA 94244-2310 PO Box 932345 (916) 657-5564 Sacramento, CA 94232-3450 (916) 657-7732 Print 4 of 4 Clear Form INF 1130 (REV. 10/2013) WWW