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Application For Direct Access Record System DR-085 - Maryland

Application For Direct Access Record System Form. This is a Maryland form and can be used in Motor Vehicle Administration Statewide .
 Fillable pdf Last Modified 2/22/2010
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Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 DR-085 (07-09) ORIGINAL RENEWAL Application for Direct Access Record System (DARS) COMPANY NAME (Include Trade Name) ________________________________________________________________ A B _________________________________________________________________________________________________ P.O. BOX STREET ADDRESS _________________________________________________________________________________________________ CITY STATE ZIP CODE BUSINESS TELEPHONE FAX NUMBER Mailing address and contact person to receive correspondence and billing: _________________________________________________________________________________________________ NAME _________________________________________________________________________________________________ STREET ADDRESS CITY STATE ZIP CODE List name and all other requested information of Owner, Partners, or Officers and Directors: (Attach extra sheet if necessary) _________________________________________________________________________________________________ NAME OF OWNER, PARTNER OR OFFICER POSITION TELEPHONE (HOME) C D E _________________________________________________________________________________________________ STREET ADDRESS (HOME) CITY STATE ZIP CODE _________________________________________________________________________________________________ NAME OF OWNER, PARTNER OR OFFICER POSITION TELEPHONE (HOME) _________________________________________________________________________________________________ STREET ADDRESS (HOME) CITY STATE ZIP CODE List names and addresses of Agents to be issued user ID Numbers on reverse side of this Application Description of Present Computer Terminal Equipment to be used with DARS System: ____________________________ _________________________________________________________________________________________________ Technical Support Staff Contact: ______________________________________________________________________ NAME (PLEASE PRINT) TELEPHONE NUMBER Monthly Volume of Records: __________________________________________________________________________ Purpose for which this information will be used: __________________________________________________________ _________________________________________________________________________________________________ This is to certify that the statements made herein are true and correct to the best of my knowledge and belief. F _________________________________________________________________________________________________ SIGNATURE TITLE DATE MVA USE ONLY APPROVED APPROVED DISAPPROVED DISAPPROVED DIRECTOR: ___________________________________________________ MVA DIRECTOR: ____________________________________________________ ISC Return completed Application to address shown on reverse side For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service representative), From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.marylandmva.com American LegalNet, Inc. www.FormsWorkFlow.com List Names and Addresses of Persons to be issued User Identification Numbers (User ID for access to system). PRINT FULL NAME OF AGENT HOME ADDRESS A ___________________________________________________________________________________________________________________________________ B ___________________________________________________________________________________________________________________________________ C ___________________________________________________________________________________________________________________________________ D ___________________________________________________________________________________________________________________________________ E ___________________________________________________________________________________________________________________________________ F ___________________________________________________________________________________________________________________________________ G ___________________________________________________________________________________________________________________________________ H ___________________________________________________________________________________________________________________________________ I ____________________________________________________________________________________________________________________________________ J ___________________________________________________________________________________________________________________________________ K ___________________________________________________________________________________________________________________________________ L ___________________________________________________________________________________________________________________________________ M___________________________________________________________________________________________________________________________________ N ___________________________________________________________________________________________________________________________________ O ___________________________________________________________________________________________________________________________________ P ___________________________________________________________________________________________________________________________________ Q ___________________________________________________________________________________________________________________________________ R ___________________________________________________________________________________________________________________________________ S ___________________________________________________________________________________________________________________________________ T ___________________________________________________________________________________________________________________________________ U ___________________________________________________________________________________________________________________________________ V ___________________________________________________________________________________________________________________________________ W __________________________________________________________________________________________________________________________________ X ___________________________________________________________________________________________________________________________________ Y
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