Maryland > Statewide > Motor Vehicle Administration
Request For Motor Vehicle Administration Records DR-057 - Maryland
| Request For Motor Vehicle Administration Records Form. This is a Maryland form and can be used in Motor Vehicle Administration Statewide . |
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Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 DR-057 (11-12) Certified Record: $12.00 Non-Certified Record: $9.00 Request for Motor Vehicle Administration Records Please complete all requested information as applicable. Subject of Record: Type of Record: r 3 year driving record r Vehicle record r *Complete driving record (all information in MVA data base). Tag No.: r *PBJ driving record VIN: Yr./Make/Model: r Driver Record Name: DOB: LIC #: Address: *Available to: individual of record or individual's attorney; police or judicial system; authorized representative of any federal, state or local government; or authorized employer of CDL drivers. r Application for driver's record/identification card. r Title record. r Certified copy of Maryland title for export of vehicle. r Registration record. r Original issue date of license. r Other: Requestor Information: Name: LIC #: Address (Home): Telephone (Home): Address (Work): Telephone (Work): Please complete this section if record is to be mailed. Please print or type information. Full Name: Street Address: City: State: Zip Code: Identification: Type of Identification Accepted: LIC #: Other Number: Verified By: Status: r Attorney (Please sign "Attorney Certification" if requesting complete driving record of your client) "I certify that I am the attorney for the individual whose complete driving record or PBJ is being requested." Attorney's Signature: r Business Name: r Law Enforcement/Government Agency Name: r Insurance Company Name: r Employer: "I certify that I am an employer or potential employer of the individual for whom I am requesting/receiving a driving record, and that a valid commercial driver's license is required of the individual as a condition of employment." Employer's Signature: Printed Name: Purpose of Request: r Researcher: r Own record: r Other: Please specify: My signature acknowledges, under penalty of criminal prosecution, that I will use information received from the Motor Vehicle Administration (MVA) solely for the purpose I describe on this application, and further agree that I will not release personal information obtained from MVA records except as permitted by §10-611, 10-616, and 10-626 of the State Government Article. I understand and acknowledge that by requesting information from Motor Vehicle Administration Records I have read and agree to the terms of the MVA Privacy Protection Agreement on the reverse side of this form. I also acknowledge that I have read the Notice of Appeal Procedure also set forth on the reverse side. Signature: MVA Use Only: Printed name: Certified Non-Certified Cash Check Credit Card Gratis For more information, please call: 410-768-7000 (to speak with a customer service representative). TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov Part 1 - Accounting Copy Part 2 - Office Copy Part 3 - Customer Copy American LegalNet, Inc. www.FormsWorkFlow.com MVA Privacy Protection Agreement Use of information obtained through this Request is governed by Federal and State laws. It is the responsibilityof the Requestor to insure that all use of information obtained through this Request complies with all applicable Federal and State laws. By signing this "Request for Motor Vehicle Records", the Requestor certifies that the Requestor, (if applicable) Requestor's employer and employees: 1. Understand that federal laws affect access to and use of computer information including, but not limited to, 15 U.S.C.A. § 278g-3 (Computer Security Act of 1987); 23 U.S.C.A § 401 (National Driver Register Act); 5 U.S.C.A § 552 (Freedom of Information Act); 5 U.S.C.A. § 552a (Privacy Act of 1974); 18 U.S.C.A. § 1001 (Computer Fraud and Abuse Act of 1986); 17 U.S.C.A. § 109 (Computer Software Rental Amendments Act of 1990); 15 U.S.C.A. § 1681 (Fair Credit Reporting Act); and, 18 U.S.C.A. §§ 2721 et seq. (Driver's Privacy Protection Act of 1994). 2. Understand that the Maryland Department of Transportation Office of Transportation Technology Services, its client agencies and their customers also adhere to State data processing security policies as set forth in Executive Order 01.01.1983.18 (Privacy and State Data System Security); Md. Code Ann., Crim. Law §8-606 (falsification of public records) and §7-302 (unauthorized access); Md. Code. Ann., State Gov't §§ 10-611, 10-616 and 10-626 Secretary of the Department of Budget and Management from time to time under Md. Code Ann., State Fin. & Proc. § 3-403. 3. Agree to maintain in strictest confidence and not willfully disclose to any person, firm, or corporation information obtained as a result of their access to personal information from motor vehicle records. 4. Are familiar with all provisions of the federal Driver Privacy Protection Act of 1994, 18 U.S.C.A. §§ 2721 et seq., and with §§ 10-611, 10-616, 10-626 of the State Government Article and §§ 12-111 through 12-113 of the Transportation Article, Annotated Code of Maryland, which limit access to personal information from public records in Maryland. The Requestor in behalf of itself, its successors and assigns further agrees that all users will abide by the terms of both the federal and state law including, but not limited to, those restricting access to personal information from Motor Vehicle Administration records only to those persons and for those purposes which are permitted under both laws. 5. Agree to keep a record for five (5) years of persons to whom information is redisclosed under this Agreement, and the purpose for which the information is to be used; and, to make that record available to the Motor Vehicle Administration upon request. 6. Shall be liable for, and shall indemnify, defend and hold the Motor Vehicle Administration harmless for any misuse or misappropriation of any personal information in a record obtained from the Administration in connection with this Agreement, including, without limitation, reasonable attorneys' fees and all other costs of litigation. 7. Shall further indemnify the Motor Vehicle Administration for and against any and all losses, damages, judgments, liabilities, or similar costs and expenses which arise in whole or part out of acts or omissions by the client with respect to laws restricting access to and disclosure of vehicle records including, without limitation, reasonable attorneys' fees and all other costs of defending against such action or claim Notice of Appeal Procedure In accorda
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