I am requesting my own record (If this box is checked, a Permissible Uses box does not need to be checked below).
Permissible Uses – I understand that the DPPA, as adopted in Arizona law, requires me to have a permissible use for requesting and receiving an MVD record
that contains personal identifying information (e.g., a person’s driver license photograph/image, driver license number, name, address and medical/disability
information). Based on the specific uses checked below, I hereby certify that I am entitled to obtain the requested record under the authority of ARS Title 28,
Chapter 2, Article 5.
For use by any government agency, including any court or law enforcement agency, in carrying out its functions or any private person or entity acting on
behalf of a government agency in carrying out its functions (Permissible Use #1)
For use by an attorney licensed to practice law or by a licensed private investigator in connection with any civil, criminal, administrative or arbitration proceeding
in any court or government agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation and the execution
or enforcement of judgments and orders, or pursuant to a court order
(Permissible Use #4)
For use by any insurer that writes automobile liability or motor vehicle liability policies and that is under the jurisdiction of the department of insurance or
insurance support organization or by a self-insured entity or its agents, employees or contractors in connection with claims investigation activities and
antifraud activities, rating or underwriting (Permissible Use #6)
For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver license that is required under the
commercial motor vehicle safety act of 1986 (49 U.S.C. 31301 through 31317) (Permissible Use #9)
For any other use in response to requests for individual motor vehicle records if the state has obtained the express consent of the person to whom the
personal information pertains (two Primary Criteria and one Secondary required) (Permissible Use #11)
For use by any requester if the requester demonstrates he or she has obtained the written consent of the individual to whom the information pertains (signed and
notarized Consent to Release Motor Vehicle Record–One-Time, form # 96-0463, must be attached) (Permissible Use #13)
Only if a box is checked for one or more of the six permissible uses above, may the requester specifically request the
person’s driver license photograph/image or medical/disability information.
Photo/Image (select locations only)
Uncertified Certified
CDL Use – uncertified (only the following users or their authorized agents may receive the designated information): For use by States, Secretary
of Transportation, Driver, Motor Carrier or Prospective Motor Carrier (49 CFR 384.225)
For use in connection with matters of at least one of the following: (a) Performance monitoring of motor vehicles, motor vehicle parts and dealers (b) Motor
vehicle market research activities, including survey research (c) Removal of non-owner records from the original owner records of motor vehicle
manufacturers (Permissible Use #2)
For use in the normal course of business by a legitimate business or its agents, employees or contractors, but only: (a) To verify the accuracy of personal
information submitted by the individual to the business or its agents, employees or contractors; or (b) If the information submitted is not correct or is no longer
correct, to obtain the correct information for the purpose of preventing fraud by, pursuing legal remedies against or recovering on a debt or security interest
against the individual
(Permissible Use #3)
For use in research activities and for use in producing statistical reports if the personal information is not published, re-disclosed or used to contact
individuals (Permissible Use #5)
For use in providing notice to the owners of towed or impounded vehicles (Permissible Use #7)
For use by any licensed private investigative agency or licensed security service, as indicated by an additional permissible use (You must check a second
permissible use.) (Permissible Use #8)
For use in connection with the operation of private toll transportation facilities (Permissible Use #10)
For any other use that is specifically authorized by law and that is related to the operation of a motor vehicle or public safety, including the following (check at
least one more of the following):
(a) Use by a financial institution or enterprise under the jurisdiction of the Department of Financial Institutions or a federal monetary authority
(b) Use by a motor vehicle dealer who is licensed and bonded by the Department or a state organization of licensed and bonded motor vehicle dealers
(c) Use by a person who is involved in an accident or the owner of a vehicle involved in an accident if the person who requests the information submits proof
to the Department of involvement in the accident
(d) Use by a person applying for a bonded title if all of the following conditions exist: (i) The requester verifies to the satisfaction of the Director that the vehicle
on which the requester is requesting the record is in the requester’s possession (ii) The record is requested in order for the requester to notify the registered
owner of the requester’s intent to apply to the Department for a bonded title (iii) The requester provides a verification of a vehicle inspection that was
performed by an authorized Department employee or agent
(e) Use by an operator of a self-service storage facility who alleges both of the following: (i) That the vehicle on which the operator is requesting the record is
in the operator’s possession (ii) That the record is requested to allow the operator to notify the registered owner and any lienholders of record of the operator’s
intent to foreclose its lien and to sell the vehicle (Permissible Use #14)
Certification – I hereby certify, under penalty of perjury, that any records or information obtained pursuant to this request will be used solely for the uses
indicated on this form, and for no other use. I understand that I am prohibited from selling or disclosing the personal information set forth in these records,
except in accordance with applicable law. I further acknowledge that MVD, by giving me access to the requested record information, is relying on the truth of the
representations contained on this form, and I am intending that MVD so rely. I therefore agree to defend, hold harmless and indemnify MVD and any of its
officers, employees, agents or contractors, from all actions brought or damages alleged by reason of the negligent, improper or unauthorized use or
dissemination of the information provided to me by MVD.
Requester Name (first, middle, last, suffix)
Acknowledged before me this date.
Notary or MVD Agent Signature
Federal Tax Identification/Vendor or Professional License Number
Applicable Licensing Agency
Professional License Number
Court Name and Case Number (if available)
