Georgia Bulk Requestor Re-certification Package Must Include:



Similar documents
Disclosure and Authorization to Obtain Information

Volunteer Driver Application Form

FINANCIAL CASUALTY & SURETY, INC. ALLIANCE SURETY SERVICES PO Box 393, Greenville, SC \ Phone Fax

CLASS B LIMOUSINE CARRIER CERTIFICATE

Kentucky Motor Vehicle Commission SALESPERSON LICENSE APPLICATION IMPORTANT NOTICE REGARDING ALL SALES PERSONNEL

APPLICATION FOR LICENSURE AS AN INSTALLMENT SELLER

Employment Application

An Equal Opportunity Employer

GEORGIA DEPARTMENT OF PUBLIC SAFETY MCCD, REGULATIONS COMPLIANCE P.O. Box 1456 ATLANTA, GEORGIA (404) OR (404)

Application for Registration or Renewal of Athlete Agent

Procedures for Compliance with The Fair Credit Reporting Act (FCRA)

APPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE

INFORMATION FOR APPLYING FOR A USED MOTOR VEHICLE DEALERS LICENSE

APPLICATION FOR EMPLOYMENT FOR DEPUTY ATTORNEYS GENERAL

Solicitor Permit Application

HOUSE BILL No page 2

Maryland Insurance Administration Individual Producer License Renewal / Reinstatement Checklist

CREDIT SWEEPERS & ASSOCIATES LLC

General Contractor License - Application

INFORMATION FOR APPLYING FOR A USED MOTOR VEHICLE DEALERS LICENSE

DRIVER EMPLOYMENT APPLICATION Name (first, middle, last) Date: Hire Date (office use only) New Hire Re-Hire Position Applying For: Full Time Part Time

The Licensing Division will not process an incomplete application or an application submitted before the application fee is paid

HOW TO COMPLETE THE EMPLOYMENT APPLICATION Thank you for your interest in employment with the Tohono O odham Nation!

INSTRUCTIONS FOR COMPLETING A DEALER LICENSE APPLICATION

On Behalf Of/Child Care Provider Criminal Offender Record Information (CORI) Request Form

GUIDE TO SECOND HAND MOTOR VEHICLE DEALER LICENSES

MASSACHUSETTS STATE LOTTERY COMMISSION

*NOTICE * THIS APPLICATION WAS REVISED IN JUNE 2015 PLEASE READ CAREFULLY

GEORGIA BOARD OF PHARMACY 2 Peachtree Street, N.W. 36 th Floor Atlanta, Georgia 30303

MASSAGE THERAPIST LICENSE APPLICATION. SSN: MN Tax ID: FEIN: City: State: ZIP Code:

Apply Today. If your application is approved, please allow 3-4 weeks to receive your Secured Visa credit card.

ROCKDALE COUNTY FINANCE DEPARTMENT PROCUREMENT OFFICE 958 MILSTEAD AVENUE CONYERS, GA

Professional Liability Insurance Application Claims Made Basis. Short Form

ASSOCIATED LICENSEE LOAN MODIFICATION CONSULTANT, FORECLOSURE CONSULTANT AND COVERED SERVICE PROVIDER APPLICATION FOR RENEWAL OF LICENSE AND CHECKLIST

Sec Certificates of use.

Application for General Contractor License

Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing

MASSAGE THERAPIST LICENSE APPLICATION

This application meets the screening requirements for the following areas:

THIS RENEWAL IS DUE ON OR BEFORE DECEMBER 1, 2015 DEBT MANAGEMENT ACT 2016 LICENSE RENEWAL CHECKLIST

State of Utah Department of Commerce Division of Occupational and Professional Licensing

RULE. Office of the Governor Real Estate Appraisers Board. Appraisal Management Companies (LAC 46:LXVII.Chapters )

OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST

Business Line of Credit

Instructions to Complete a DBA application:

INSTRUCTIONS FOR FILING A CONDOMINIUM / COOPERATIVE COMPLAINT

MASSACHUSETTS STATE LOTTERY COMMISSION LICENSE APPLICATION BOOKLET

INFORMATION FOR ASBESTOS HANDLING LICENSE APPLICANTS

APPLICANT INFORMATION (please print or type)

How To Become A Real Estate Salesperson In New York

Commercial Loan Application. Personal Financial Statement. Certification of Personal Financial Statement

ONLINE BANKING ENROLLMENT FORM. Customer Information. Security and Identification Information. Bank Use

Criminal Offender Record Information (CORI) Attorney Request Form

How To Get A Transporter Tag In Martha Michael

Application for Rental

Initial Application for Debt Management License Attachments and Instructions

New Mexico Office of Superintendent of Insurance Producer Licensing Bureau

Please be mindful that the most commonly omitted items from the New DUI Program Application are: Completed application for each stakeholder/ partner

SHORT FORM For Use by presently certified firms.

APPLICANT INFORMATION (please print or type)

Application for Employment

How To Register With The Credit Bureau

SELLER TRAINING INTERNET-BASED BRANCH SCHOOL CERTIFICATE APPLICATION FORM ST-401IBB (02/2011)

Application for License as Home Inspector passport sized color photographs of head and shoulders. Photos must be of

CERTIFIED MEDICAL LANGUAGE INTERPRETER

Application for Employment

State of New Jersey Department of Labor and Workforce Development Division of Wage and Hour Compliance PO Box 389 Trenton, New Jersey

City of South Portland Office of the City Clerk P.O. Box 9422 South Portland, ME

GENERAL INSTRUCTION COMMON VICTUALLER APPLICATION

SUPREME COURT OF PENNSYLVANIA DOMESTIC RELATIONS PROCEDURAL RULES COMMITTEE RECOMMENDATION 140

OCCUPATIONAL TAX CERTIFICATE

LEASE APPLICATION RESIDENCY INFORMATION

Pedicab and Neighborhood Electric Vehicle (NEV) Certificate of Operation Application Guide

City of Austin Application for Massage Therapy or Massage Establishment License City of Austin th Avenue NE

DRIVER S APPLICATION FOR DOT CERTIFICATION PREVIOUS THREE YEARS RESIDENCY APPLICATION INFORMATION EMERGENCY CONTACT DRIVING EXPERIENCE

County of Accomack, Virginia Business License Application Calendar Year 20

iix, An ISO Business Insurance Subscription Agreement

BENCHMARK MEDICAL LLC, BUSINESS ASSOCIATE AGREEMENT

Appraisal Management Company (AMC)

Application for Solicitor License 2750 Kelley Parkway, Orono, MN Phone: / Fax:

STATE OF CONNECTICUT INSURANCE DEPARTMENT

CTP 5037 (11/11) Page 2 of 6

Name(s): Phone: Emergency Contact & Phone: VIRTUAL MAILBOX AGREEMENT

Fair Credit Reporting Act. ** Summary and Forms **

Transcription:

Georgia Bulk Requestor Re-certification Package Must Include: Georgia Department of Driver Services Application for Motor Vehicle Records (1 page) Facilitator Addendum to the Bulk Requestor Agreement (1 page) DDS Bulk Requestor Certificate (2 pages) Company Business License, Professional License, Occupational License and/or Private Investigator s License The Georgia Department of Driver Services will not approve your account if the required documentation of one of these licenses is not provided with your application. All state fees must be paid for the current year and the business license must be dated. If your license will expire during the certification period, a new license must be sent into the DMVS MVR Unit, or your account will be disabled. Out of state companies must provide the phone number of the Secretary of State and the county licensing office for the state in which they do business. *All entries including signatures must be legible. No photocopies or facsimiles will be accepted. Mail the original Georgia Re-certification to: Driver Services Section/Motor Vehicle Records PO Box 80477 Conyers, GA 30013 IMPORTANT: Do not mail or fax Re-certification to Softech. 1. Georgia Driver Division Services will review your application. Incomplete application will not be certified. If your package is incomplete, it will be returned to your office with a letter stating why it was returned. 2. If the application is denied, a letter of denial will be sent to you outlining the reasons why. *When the Re-certification is received* If the application is accepted, DDS will mail a certification notice/information letter to you. Included in this package will be your Customer ID, User ID, and Password. There will also be a letter displaying your cortication dates at the bottom of the page. Both pages must be forwarded to Softech for continued access to Georgia Driving Records. This notice may be faxed to Softech at 305.253.1440.

GEORGIA DEPARTMENT OF DRIVER SERVICES Attn: Bulk MVR P.O. Box 80447 Conyers, Ga. 30013 678-413-8847 APPLICATION FOR MOTOR VEHICLE RECORDS Company Name: FEIN: Company Rep./Individual Name: Existing Customer ID: Mailing Address: City: State: Zip Code: Billing Address: City: State: Zip Code: Telephone Number: Fax Number: Type of Business: (Select only one) Court Financial Institution Insurance Law Enforcement School City Government County Government Fire Dept. Car Rental Corporation State Agency Other Type of Certification Requested: (Select only one) Internet User Bulk Requestor Bulk User Purpose For Requesting MVRs: (Select all that applies) Motor Vehicle Insurance Motor Vehicle Limited Rating Information Other Insurance Credit Rental Car Agency Other Employment (own employees) Employment (background check done for hire) Security Question: (Answer only one of the following questions) What is your mother s maiden name? Answer: What is your pet s name? Answer: What is your favorite color? Answer: What is your favorite food? Answer: What is your birth month? Answer: E-mail Address: Do you have a contract with a state agency that requires you to request MVRs? Yes No If so, you will need to send in a copy of that contract with your signed application. By signing this application, I hereby certify the above information is true and correct and the information obtained will be used for the purpose stated above and in accordance with the Fair Credit Reporting Act. SIGNATURE PRINTED NAME OF APPLICANT DATE TITLE

GEORGIA DEPARTMENT OF DRIVER SERVICES BULK MVR REQUESTOR CERTIFICATE Name: Address: City: State: Zip Code: Telephone #: Fax #: Email: The company or individual named above certifies that it shall obtain driving records on behalf of Users. The Requestor shall submit a Bulk MVR User Certificate to the Department of Driver Services (DDS) for each User availing itself of the Requestor s access to the DDS driving records. For each driving record requested, the information contained therein shall be used by the Requestor s Users solely for one of the following approved purposes: insurance claims investigation, insurance antifraud activities, insurance rating, insurance underwriting, car rental agreements, address verification by creditors, or background investigations by employers or applicants for employment. In the event that an adverse decision is based upon any information supplied to the company by the DDS, then upon request of the driver named in the driving record, the User or the Requestor shall inform the named driver of all information pertinent to the decision. This provision is to be construed as requiring the User or Requestor to include specific information included in the driver s operating record. All information is requested only for the exclusive use of the Requestor s Users. Neither the Requestor, nor its Users, shall not share, sell or otherwise disseminate any information included in the motor vehicle report to any other person or company, except as provided in O.C.G.A. 40-5-2, 18 U.S.C. 2721, et seq., Ga. Admin. Comp. Ch. 375-3-8-.03, any other applicable provision of law, or as provided herein. Any violation of the rules, laws or agreements applicable to the access provided herein to the User shall be considered sufficient grounds for the DDS to refuse to release any additional information on any other driver that the Requestor may request. This administrative action by the DDS shall not be deemed to supersede any other sanctions prescribed by law, including, but not limited to, any applicable civil or criminal penalties. The DDS has the right to inspect and copy all records, files, reports, or any other materials deemed necessary to verify that the Requestor and its Users have abided by all terms of the certificate unless such access is prohibited by law.

The burden of showing compliance with the provisions of this certificate is at all times on the Requestor. Upon reasonable notice by the DDS, the Requestor must be able to demonstrate such compliance. Requestors obtaining driving records for any of the aforementioned insurance purposes shall only do so if its Users have an application for insurance or renewal thereof for each driver who is the subject of such records. Requestors obtaining driving records for Users to conduct background investigations on their employees or applicants for employment must obtain the written consent of each licensee whose driving record is requested. Access granted to this Requestor s Users shall cease immediately if the DDS terminates the Requestor s access to driving records for any reason. Termination, non-renewal, or expiration of the Requestor s agreement with the Georgia Technology Authority terminates the Requestor s access to driving records for any reason. The person signing below has authority to do so on behalf of the applicant named above. Date Signature Title/Position Printed Name