State of New Mexico - MVD, Application for Approval

	State of New Mexico - Motor Vehicle Division APPLICATION FOR APPROVAL TO ACCESS MOTOR VEHICLE CODE RECORDS Under Sec. 66-2-7.1 NMSA 1978 (Motor Vehicle Code Confidentiality)
Please print clearly or type / All items must be completed

MVD USE ONLY

Agreement Number

Date Received

Requestor Code

Expires

This form is in 4 parts. All parts must be completed in full, signed, and notarized
before it can be considered.
Submittal of this form does not guarantee approval for access to MVD records.

If the status of any person listed on this form or attachments changes, or
if any new names are to be given access, a new form must be submitted.

PART A: BUSINESS IDENTIFICATION
Business Name	CRS Identification Number
Business Address	Federal Employer Identification Number
Mailing Address (if different)
City	State	Zip Code
Contact Name	Telephone Number

PART B: OWNERSHIP / CONTROL INFORMATION
List name, title and Social Security Number (SSN) of each owner, partner, shareholder or employee primarily responsible for control or management of the business. Attach additional sheet in same format if necessary.
Name	Title	SSN
Name	Title	SSN
Name	Title	SSN
Name	Title	SSN
Name	Title	SSN

PART C: BUSINESS INFORMATION

1. Form of Business	Sole Proprietor	Partnership	Corporation	Government
	Other _______________________________________________________

2a. Has this entity, or a predecessor entity, applied for or been granted MVC Access Approval?

Yes

No
If yes, enter the prior Agreement Number(s) ____________ and Requestor Code(s) ____________
2b. Has this entity, or a predecessor entity, had MVC Access denied, suspended or revoked?

Yes

No
If yes, attach a detailed explanation on a separate sheet of paper.

3. Is the business required to be licensed or regulated by any state or federal government entity?

Yes

No
If yes, attach a statement of explanation or a copy of any license.

4. For purposes of this Application and any related Access Agreement, the term "Personal Information:" means:

• with respect to vehicle records, driver license number, date of birth, address, city, state; and

• with respect to driver records, name, address, city, state, social security number, driver license number,

date of birth, height, weight, medical restrictions, image, signature.
Carefully read these allowable uses of "Personal Information" and check the use for which you seek access approval.

Use by any governmental agency, including any court, in carrying out its functions or by any private person acting on behalf of the government; OR

Use in connection with matters of motor vehicle and driver safety or theft; motor vehicle emissions; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; motor vehicle production alterations, recalls or advisories and removal of non-owner records from original owner records of motor vehicle manufacturers; OR

Use in research activities, and for use in producing statistical reports so long as the Personal Information is not published, redisclosed or used to contact individuals; OR

Use by any insurer or insurance support organization or by a self-insured entity or its agents, employees or contractors, in connection with claims investigation activities, antifraud activities, rating or underwriting; OR

Providing notice to owners of towed or impounded vehicles; OR

Use by an employer or its agent or insurer in obtaining or verifying information relating to a holder of a commercial driver's license.

None of the above.

5. Will the persons named in PART B of this application be the

sole users or will

other users be given access to MVD records? If other users are anticipated, attached a list of those users' names, Social Security Numbers, and relationship to the applicant.

Are any persons you want to be authorized for access to MVD records a convicted felon?
Yes No
If Yes, give name(s) and Social Security Number:

6. In your own words, please explain your use of the information obtained from your access to MVD records (use extra paper if necessary):

PART D: AGREEMENTS, SIGNATURE and NOTARIZATION

Please check each box to indicate your acceptance and understanding of each statement.

	I understand that false or misleading statements in this application can be the basis for denial of this Application or revocation of an Access Agreement. The Motor Vehicle Division is specifically authorized to investigate in any statement in this Application.
	If this Application is approved, I understand I will be required to sign an Access Agreement, which will specify the terms and conditions governing such access, and will become a part of this Application. Any deviation from the terms and conditions may be considered by the Department as a breech of the Agreement, and could result in revocation of the Agreement and denial of future applications.
	I understand it is unlawful to disclose to any person any Personal Information obtained through an Access Agreement, or to use any Personal Information for any purpose not allowed by law under Sec. 66-2-7.1 NMSA 1978. A violation of these provisions is a misdemeanor and, if convicted, is punishable by a fine not exceeding $1,000 or by imprisonment in the county jail for a period not exceeding one year, or both.
	I agree to notify the Department within ten (10) business days of any change to any information in this application.

I certify under penalties of perjury that I am authorized to sign this Application for Approval to Access Motor Vehicle Code Records under Sec. 66-2-7.1 NMSA 1978 and to bind the applicant to all conditions of an Access Agreement, and that all information contained in this Application is true, correct and complete, to the best of my knowledge and belief.

Name (Typed or printed)

Title

Signature

Date

Subscribed and sworn to before me at _______________________ this ___ day of ___________, 19___.

______________________________________
Notary Public

My Commission expires ______________________

Mail completed Application, with all required attachments to:

Oso Grande Technologies, Inc.
5921 Jefferson, N.E., Suite A
Albuquerque, NM 87109-4442

Document URL -- http://www.technet.nm.net/menu/mvd-app.htm
Last modified: June 16, 1998