RMV 2/15/2013
This form is used when an Authorized User’s password expires, or an Authorized User needs additional
access for central processing purposes. If your password is expired and you have processed a transaction
within the last 90 days, please complete this form and fax it to 857-368-0821. This form is required to be
signed by the Dealer Principal, Comptroller, or EVR Supervisor. Contact your service provider helpline
within 48 hours to confirm password has been activated.
DATE_________________
DEALERSHIP/AGENCY_____________________________________________________________
ADDRESS________________________________________________________________________
TELEPHONE NUMBER_______________________FAX NUMBER___________________________
Statement of Authorized User
I understand that if my password expires 3 times in a calendar year, I will not be permitted to continue as an
Authorized User on the EVR Program.
Signature of Applicant: _____________________________________________________________
Statement of Authorized Dealer/Agent Representative
I understand that if an Authorized User’s password expires 3 times in a calendar year, they will not be
permitted to continue as an Authorized User on the EVR Program. All Authorized End Users should
process work on a regular basis to keep their password in an active status.
Applicant ‘s Supervisor Signature_____________________________________________________
Print Name _______________________________ Position_________________________________
EVR PROGRAM
REQUEST FOR RE-AUTHORIZATION
AUTHORIZED EVR USER INFORMATION
NAME__________________________________________________________________________________
LAST FOUR DIGITS OF YOUR SS#__________________________________________________________
SIGNATURE____________________________________________________________________________
REASON FOR REQUEST (CHECK ONE): EXPIRED PASSWORD ADDITIONAL ACCESS
ADDITIONAL ACCESS LOCATION (S) :_____________________________________________________
RMV USE ONLY REQUEST #__________ DATE____________ APPROVED BY___________
