Fillable APPLICATION FOR EXTRANET TRANSACTION ACCESS (Virginia Department of Motor Vehicles)

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APPLICATION FOR EXTRANET TRANSACTION ACCESS (Virginia Department of Motor Vehicles)

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APPLICATION FOR EXTRANET
TRANSACTION ACCESS
US 532 E/ER (04/13/2020)
PURPOSE: This application must be used when applying for or renewing an existing Memorandum of Understanding and
Agreement (MOA) with the Department of Motor Vehicles (DMV). An MOA is needed when obtaining driver,
vehicle and/or personal information from DMV's record database or providing information to DMV's record
database via the Internet (extranet).
INSTRUCTIONS:
1. Complete in ink or type. If you downloaded this application from DMV's website you may complete it online. However,
you must print the form and sign it.
2. Complete all applicable parts of the application. Be as specific as possible. If additional space is needed, attach
additional pages. Write N/A beside any part(s) or question(s) that do not apply.
3. Have an authorized agent or representative of the applicant sign and date the application. Unsigned or incomplete
applications cannot be processed and will be returned to the applicant.
4. If also completing a Commercial Information Use Application, form US 532A, or a Government Information Use
Application, form US 532B, with this application, only one $25 application fee is required. Non-profit and charitable
entities specified in Virginia Code §46.2-208, unless exempt from fees based on this code section, are subject to an
application fee of one-half the normal fee or $12.50.
5. Mail the completed application and the appropriate application fee to the address below.
Use Agreement Services
Virginia Department of Motor Vehicles
Post Office Box 27412
Richmond, Virginia 23269-0001
Fax: 804-367-2536
SPECIAL APPLICATION NOTES AND PROVISIONS
► This application is subject to change based on changes in state or federal laws, rules, and regulations governing access
and use of the requested information.
► By submitting this application, the applicant agrees to comply with all rules, laws, and regulations governing access to
DMV records and the information they contain, including the Virginia Code §§ 18.2-152.1 through 18.2-152.14 and the
federal Fair Credit Reporting Act, Public Law 91-508.
► Violation of the state laws concerning use of DMV information and files is punishable under state law as a Class 4
misdemeanor. Violations of federal Fair Credit Reporting Act, Public Law 91-508 and the provisions therein are
punishable by a fine up to $5,000 or two years imprisonment or both.
► When approved, users are subject to reasonable inspection and/or audit by DMV to ensure compliance with the terms
and provisions stated in the Memorandum of Understanding and Agreement.
► Applications with false, misleading, or otherwise deceptive information will not be processed and may be grounds for
criminal prosecution under state and federal law.
The following are standard requirements of a DMV Extranet Memorandum of Understanding and Agreement:
► All extranet users shall, at their own expense, comply with and maintain compliance with all Commonwealth of Virginia
IT security policies, standards, and guidelines, including and revisions, amendments, and/or successors thereto. All
extranet users shall make all necessary modifications to comply with and maintain compliance with all revisions, updates,
modifications, and/or successors to such policies, standards, and guidelines at its own costs. All extranet users also
shall, at their own expense, comply with and maintain compliance with the DMV IT Architecture and Security Documents,
as may be amended from time to time.
• Copies of the current Commonwealth of Virginia IT security policies, standards, and guidelines are available on the
VITA Website at http://www.vita.virginia.gov/library/default.aspx?id=537#security_docs.asp
.
• Copies of the most recent DMV IT Architecture and Security Documents are available on the DMV Website at
http://www.dmv.virginia.gov/webdoc/general/security_docs.asp.
All extranet users will be responsible for reviewing these websites for revisions, updates and/or modifications at least
once every six months.
► Antivirus Requirements: Extranet User understands and agrees that each and every electronic device used to access
data stored on DMV Systems must have commercially available Antivirus software installed and actively running on the
device, and that the Antivirus software must be maintained with up to date virus definitions.
► Audit Requirements: DMV reserves the right to audit User to confirm compliance with all requirements in the DMV
Memorandum of Understanding and Agreement. User shall provide DMV with full access to and the opportunity to
examine any records, electronic devices, and/or other materials necessary to perform such audits.
APPLICATION FOR EXTRANET
TRANSACTION ACCESS
US 532 E/ER (04/13/2020)
The information below is required by the State Comptroller for debt set-off collection purposes in accordance with the of Virginia
Code §§ 2.2-803 and 2.2-4800, et al. Print or type
PART 1: USER INFORMATION (All applicants must complete this part.)
CURRENT DATE (mm/dd/yyyy)
BUSINESS NAME
TYPE OF APPLICATION (check the appropriate box)
RENEWALNEW APPLICANT
CURRENT DMV USE AGREEMENT NUMBER
TYPE OF BUSINESS
DEALER CERTIFICATE NUMBER(S) (required for dealers only)
CITY STATE ZIP CODE
TELEPHONE NUMBER FAX NUMBER
BUSINESS EMAIL ADDRESS
CITY STATE ZIP CODEPOST OFFICE BOX
STREET ADDRESS
FEDERAL ID NUMBER OR SOCIAL SECURITY NUMBER
PART 2: TYPE OF TRANSACTIONS TO PROCESS (All applicants must complete this part.)
Check the appropriate block to indicate the type of DMV transactions you wish to conduct.
Process Financial Responsibility Insurance Certification Filings (complete Part 3 below) (No Application Fee Required)
Process Clinic Roster Submissions (Application Fee Required)
Process Independent Dealer Operator Course qualification records (No Application Fee Required)
Request Mechanic and Storage Lien Transcripts
Request Customer Information Transcripts (Voter Registrar's Only)
Temporary Tag Inventory Maintenance (No Application Fee Required)
Renew Dealer Certificate, Salesperson License, Dealer License Plates (No Application Fee Required)
Request Vehicle Transcripts
Process Local Vehicle Registration (LVR). Are you under contract with another jurisdiction to administer local vehicle
Process Conviction Reports (courts only)
Submit Insurance Filings for Motor Carriers (complete Part 3 below) (No Application Fee Required)
Submit Insurance Acknowledgment (complete Part 3) (No Application Fee Required)
registrations? If yes, list all applicable jurisdictions.
YES NO
Vehicle Disposition Reporting (Scrap Metal applicants) -- if multiple locations exists, please attach a list of all location names and
addresses (No Application Fee Required)
(No Application Fee Required)
Vehicle Disposition Reporting (Demolisher/Salvage Dealer applicants) -- please list all certificate numbers in Part 1
Submit CDL 3rd Party Road Skills Test Results (Employee Based - No Application Fee Required)
Submit Class A Driver Training School Skills Test Results (Application Fee Required)
Submit Escort Vehicle Driver Training Results (No Application Fee Required)
Submit Escort Vehicle Driver Training Results - Remote Tester (No Application Fee Required)
Submit Escort Vehicle Remote Tester Invoice Payments. (No application fee required)
Submit CDL 3rd Party Road Skills Test Results (Colleges - No Application Fee Required)
Request Driver Transcripts
Request Driver Alert Electronic Notifications
Request Compliance Summary Letter
PART 3: INSURANCE COMPANY INFORMATION (Insurance companies only)
Insurance companies must complete this part when requesting to process Financial Responsibility Insurance Certification
Filings, Insurance Filings for Motor Carriers, and Insurance Acknowledgements.
Provide the name(s) of all insurance company(ies), their insurance code(s) or the NAIC for which you will be filing. (Insurance
codes are for SR22/26, FR44/46 and Insurance Acknowledgement filers only.)
Name of Insurance Company Insurance/NAIC Code
Page 2
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APPLICATION FOR EXTRANET
TRANSACTION ACCESS
US 532 E/ER (04/13/2020)
PART 4: USER INFORMATION (All applicants must complete this part.)
Provide the names of all employees who will be authorized to use the requested access. An RSA SecurID token (required for access) will be
assigned to each employee at a fee of $65.00 each. Please remit payment along with this application.
User Name (first, middle initial, last) Mother's Maiden Name Business Email Address
All organizations with extranet transaction access must designate a security officer who is responsible for administering user logon IDs.
Provide the following information for your designated security officer.
PART 5: SECURITY INFORMATION (All applicants must complete this part.)
TELEPHONE NUMBER FAX NUMBER
BUSINESS EMAIL ADDRESS
SECURITY OFFICER NAME SECURITY OFFICER SIGNATURE
PART 6: CERTIFICATION (All applicants must complete this part.)
TITLE (print or type)AUTHORIZED REPRESENTATIVE NAME (print or type)
ZIP CODESTATECITY
TELEPHONE NUMBER FAX NUMBER
BUSINESS EMAIL ADDRESS
SIGNATURE
AUTHORIZED REPRESENTATIVE ADDRESS (if different from Part 1)
CURRENT DATE (mm/dd/yyyy)USER/BUSINESS NAME (print or type)
I, the undersigned, certify and affirm that: 1) I am a duly authorized agent of the applicant; 2) I am authorized to make application to DMV for
any information use agreement for the purpose stated in this application; and 3) all information presented in this form is true and correct, that
any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I
make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on
this form is a criminal violation.
DMV USE ONLY
APPLICATION
APPROVED DENIED
SIGNATURE
IF APPROVED, LIST DATE (mm/dd/yyyy) (USE AGREEMENT MAILED) TITLE
IF DENIED, GIVE REASON(S) DATE (mm/dd/yyyy)
Page 3
EXISTING USERS: All employees who currently have an assigned RSA SecurID token should complete the information below.
User Name
(first, middle initial, last)
Mother's Maiden Name Business Email Address Current Log On ID
RSA SecurID Token
Serial Number
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APPLICATION FOR EXTRANET TRANSACTION ACCESS (Virginia Department of Motor Vehicles)

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Completed 29 July 2020

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