Fillable COMMERCIAL INFORMATION USE APPLICATION (Virginia Department of Motor Vehicles)

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COMMERCIAL INFORMATION USE APPLICATION (Virginia Department of Motor Vehicles)

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US 532 A (04/13/2020)
COMMERCIAL INFORMATION
USE APPLICATION
PURPOSE: This application must be used when applying for, making changes to, or renewing an existing Commercial Use Agreement
with the Department of Motor Vehicles (DMV). A Use Agreement is needed when obtaining driver, vehicle, and/or personal
information from DMV's record database.
INSTRUCTIONS:
1. Complete in ink or type. If you downloaded this application from DMV's web site you may complete it online. However, you must
print the form, sign it and include attachments for Section L. Form US 532C provides information about DMV's information-use
criteria that may assist you in completing Section L. Form US 532C is available at www.dmvNOW.com
.
2. Complete all 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 an Application for Extranet Transaction Access, form US 532 E/ER, 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, supporting documents, 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 federal and state statutes, rules and regulations and all
DMV policies pertaining to personal information disseminated by DMV. Applicants are subject to the provisions of and should be
familiar with the following: the Virginia Code §§ 2.2-3800 through 2.2-3809 and §§ 46.2-208, 46.2-209 and 46.2-210; the federal
Driver's Privacy Protection Act (DPPA), 18 U.S.C. §§ 2721 through 2725; the 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.
Violation of federal Driver's Privacy Protection Act (DPPA), Law 91-508 (Fair Credit Reporting Act), and the provisions therein is
punishable by a fine up to $5,000 or two years imprisonment or both.
► 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 Commercial Information Use Agreement:
► All automated systems access 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
automated systems access 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 automated
systems access 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#securityPSGs.
• 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 automated systems access users will be responsible for reviewing these websites for revisions, updates and/or modifications
at least once every six months.
► Antivirus Requirements: Internet 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.
► Document Retention - User must maintain a list of accesses made into DMV records for three years from the date of access.
► Audit Requirements: DMV reserves the right to audit User to confirm compliance with all requirements in the DMV Use
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.
US 532 A (04/13/2020)
INFORMATION SERVICES PROGRAM
COMMERCIAL REQUESTER
INFORMATION USE APPLICATION
Purpose: Use this application when applying for, modifying, or renewing an existing commercial account.
Instructions: Mail completed application to DMV at the address above.
The information below is required by the State Comptroller for debt set-off collection purposes in accordance with Virginia Code §§ 2.2-803
and 2.2-4800, et al.
APPLICATION TYPE
Check One
Original Application - All sections must be completed. Incomplete applications will be returned unprocessed.
Change(s) to Existing Account - Complete only those sections that are changing (Required).
Renewal - All sections must be completed. Incomplete applications will be returned unprocessed.
CURRENT DMV USE AGREEMENT NUMBER
SECTION A. BUSINESS INFORMATION
BUSINESS NAME PHONE NUMBER
TRADING AS NAME (DBA) FEDERAL ID NUMBER FAX NUMBER
CONTACT PERSON NAME / TITLE EMAIL ADDRESS PHONE NUMBER
WEBSITE ADDRESS BUSINESS TYPE (corporation, LLC, LLP, etc.) STATE OF ISSUANCE
STREET ADDRESS (physical location) CITY STATE ZIP CODE
MAILING ADDRESS (if different from above) CITY STATE ZIP CODE
DMV USE ONLY
CHECK/MO/CC # AMOUNT
DATE EXPIRES
SECTION B. BUSINESS TYPE
Attorney/Law Office Insurance Agent/Agency/Broker Rental Company
Construction/Contracting Insurance Company Towing Company
DCJS Licensed Compliance Agent Lessor/Retailer Other: (Identify below)
DCJS Licensed Private Investigator Manufacturer
Dealer Mechanic/Storage Liens
SECTION C. PROFESSIONAL / OCCUPATIONAL LICENSE INFORMATION
PROFESSIONAL OR OCCUPATIONAL LICENSE NAME
ISSUING AGENCY NAME LICENSE NUMBER EXPIRATION DATE (mm/yyyy)
US 532 A (04/13/2020)
page 2
SECTION D. COMMERCIAL INFORMATION USE ACCOUNT HISTORY AND USE
1. Has anyone directly affiliated with any party identified above:
a. previously applied for, had, or have a Commercial Information Use Account? Yes No
IF YES, BUSINESS NAME AGREEMENT / ACCOUNT NUMBER
b. been subject to a DMV administrative action? Yes No
If Yes, attach a separate sheet that includes the type of action, the name of the person and/or business and the date of the incident.
2.
Has anyone having access ever been convicted of any crime for a violent act, stalking,
computer fraud, or for unauthorized disclosure, access or distribution of information?
Yes No
If Yes, attach a separate sheet that includes the name of the person, the specific code violation, conviction date, name of court and action taken.
3. I will be using the information for my own business use as approved by the department.
I will be using the information to perform a legitimate business service on behalf of another CRIUA applicant (i.e., pass through/reformat, other
contracted services) as approved by the department. Access authority will be based on the other CRIUA applicant.
SECTION E. INFORMATION DELIVERY METHOD
Check all blocks that indicate how you wish to receive the requested information.
PICK UP printed information
Receive printed information via MAIL
Request information using the Extranet (Internet) application (US 532E/ER application required)
Request information using the Secure Data Exchange
Request information through direct access to DMV Web Service
SECTION F. TYPE OF INFORMATION REQUESTED
SELECT APPLICABLE INFORMATION TYPE(S) BELOW
I am an EMPLOYER requesting Driver Record Information on employees as it relates to the driver's license status and activity.
2.
Intended Use (check all that apply)
I am a TNC requesting Driver Record Information on employees as it relates to the driver's license status and activity.
OPTION 2 -- Risk Management on current employees
OPTION 3 -- Participation in DMV's Driver Alert Program plus Risk Management. Enter the day and month you would like to receive
your annual production of driver records (mm/dd)
Immediate alert of moving violation convictions.
Immediate alert if drivers accumulate seven adverse points within a calendar year.
Immediate alert of suspensions, revocations, disqualifications, cancellations; reckless driving or driving while intoxicated
convictions.
Driver Alert Monitoring Preferences (check all that apply)
NOTE: Records produced are limited to a maximum of 9,999 drivers.
I am pursuing a MECHANIC and/or STORAGE LIEN and need Vehicle Information which includes vehicle description, title, registration
3.
Notify vehicle owner and lienholder of vehicle location and mechanic and/or storage fees due prior to mechanic and/or storage lien
Intended Use
and vehicle activity as well as current Lienholder(s).
application.
Vehicle information which includes vehicle description, title, registration and vehicle activity.
Personal information, as defined in §§ 2.2-3801.
Other (please describe
1.
Select all that apply below AND complete Section G - Permissible Use(s)/Purpose.
Driver Information
OPTION 1 -- Pre-employment Screening
US 532 A (04/13/2020)
page 3
SECTION G. PERMISSIBLE USE(S)/PURPOSE
Each permissible use must be listed separately in accordance with provisions of section §46.2-208(B)(9). DMV USE ONLY
PROPOSED USE APPROVED
Yes No
REASON CODE
1. IDENTIFY PROPOSED USE
PROPOSED USE APPROVED
Yes No
REASON CODE
2. IDENTIFY PROPOSED USE
PROPOSED USE APPROVED
Yes No
REASON CODE
3. IDENTIFY PROPOSED USE
PROPOSED USE APPROVED
Yes No
REASON CODE
4. IDENTIFY PROPOSED USE
SECTION H. INFORMATION SYSTEM CONTACT PERSON (For online access only.)
CONTACT PERSON NAME
ADDRESS (if different than applicant address)
CITY STATE ZIP CODE
TELEPHONE NUMBER FAX NUMBER
BUSINESS EMAIL ADDRESS
TITLE
SECTION I. USER LIST
Provide a list of all users and a description of the type of access needed to obtain information. Attach a separate list of names if necessary.
( )
( )
US 532 A (04/13/2020)
CERTIFICATION
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.
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)
REQUEST DATE (mm/dd/yyyy)USER/BUSINESS NAME (print or type)
Do you plan to use a third party information service? If yes, provide name of the service below.
SECTION J. THIRD PARTY USER
YES NO
SECTION K. BILLING INFORMATION
Check the block that indicates how you wish to be billed.
Pay in person AT TIME OF RECEIPT
DIRECT BILLING monthly by DMV
BUSINESS NAME
MAILING ADDRESS (street address or P.O. box, city, state and zip code)
PHYSICAL ADDRESS (street address, city, state and zip code) (do NOT enter P.O. boxes)
TELEPHONE NUMBER FAX NUMBER
BUSINESS EMAIL ADDRESS
CONTACT PERSON NAME
Attach a copy of any documents supporting the need for the requested information and verifying the identity of the company
or user. Be as thorough as possible and address the following points.
• Business license or professional license
• Company charter, annual report or financial statement
• Statement on company letterhead from the applicant user
• Other items validating the user's need as explained in Section G
• For service providers only in addition to above requirements:
o Security of records, files and systems
o Names and addresses of data extraction method and software creators/vendors
o Network diagrams and descriptions of data extraction methods and software
o Descriptions of system support processes including backup methods and frequencies
• Proposed audit/management controls over access and dissemination of requested information
• Commercial anti-virus software and frequency of updates
SECTION L. VALIDATION OF USER NEED (Must be attached to this application.)
page 4
( )
( )
( )
( )
US 532 A (04/13/2020)
INFORMATION SECURITY STATEMENT
page 5
By signing this form, the undersigned represents that he/she has read and understands the same, agrees to its content,
realizes the penalties of non-compliance to its terms, and ensures each employee given access agrees to and understands
the same.
The Department of Motor Vehicles (VA DMV) collects information from the public to administer the various programs for
which it has responsibility. VA DMV is committed to protect this information from unauthorized access, use, or disclosure.
The following have been adopted to address commercial and governmental users responsibilities for handling and protecting
information obtained from VA DMV. I understand the following are my responsibilities:
1. May access information only when necessary to accomplish the responsibilities of employment. May not access or
use information from the VA DMV for personal reasons. (Examples of inappropriate access or misuse of VA DMV
information include, but are not limited to: making personal inquiries or processing transactions on any records or
those of friends or relatives; accessing information about another person, including locating their residence address,
for any reason that is not related to job responsibilities.)
2. May disclose VA DMV information only to individuals who have been authorized to receive it through the appropriate
procedures as regulated by VA DMV. Requesters of information must complete the appropriate forms, submit them
to VA DMV as specified in the use agreement addendum, and pay all applicable fees. A proper accounting of all
disclosures must be made and the subject must be notified in accordance with statute and the VA DMV directives.
(Examples of unauthorized disclosures include, but are not limited to: telling someone the address of another person
when it is not an authorized disclosure or part of job responsibilities.)
3. To keep the requester code and/or password confidential, authorized users must take reasonable precautions to
maintain secrecy of any requester code and/or password. Reasonable precautions include, but are not limited to: not
telling or allowing others to view passwords or requester code; securing pc/laptop with a locking device; storing user
documentation to sensitive programs in a secure place; destroy VA DMV information in a manner that it cannot be
reproduced or identified in any physical or electronic form in accordance with VA addendum; and report any
suspicious circumstances or unauthorized individuals observed in the work area to supervisor, if applicable.
4. To promptly notify manager or supervisor of any indication of misuse or unauthorized disclosure of information
obtained from VA DMV.
Federal law states:
"Any person who knowingly obtains, discloses, or uses personal information from a motor vehicle record for a
purpose not permitted under the Driver's Privacy Protection Act (Title 18 of the United States Code, Section
2721-2725), shall be liable to the individual to whom the information pertains, who may bring civil action in a United
States district court.
I certify under penalty of perjury, under the laws of the State of Virginia, that I have read and understand the security policies
stated above. I understand that failure to comply with these policies and regulations may result in disciplinary action in
accordance with the state and federal laws and regulations, and/or civil or criminal prosecution in accordance with applicable
statutes. I further understand that I may undergo disciplinary action from my employer up to and including termination from
employment.
EXECUTED AT CITY COUNTY STATE ZIP CODE
SIGNATURE
DATE (mm/dd/yyyy)
SIGNATORY NAME (print)
DMV REPRESENTATIVE
This form must be completed upon presentation and re-certified annually and RETAINED AT THE WORKSITE of the
Requester Account Holder with a current list of those authorized direct or incidental record access for three years from the
date of access. The completed form and list must be made available upon request to DMV audit staff.
US 532 A (04/13/2020)
ANNUAL RE-CERTIFICATION
I have read and understand the security policies stated within the Information Security Statement. I understand that failure to comply with
these policies may result in disciplinary action in accordance with Section 19572 of the government Code, federal laws and regulations,
and/or civil or criminal prosecution with applicable statutes.
PRINTED NAME SIGNATURE DATE (mm/dd/yyyy)
page 6
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Completed 29 July 2020

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