Form Dl 9002 – Fill Out and Use This PDF

DL-9002(2-14)

INTERNET USERAPPLICATION/LICENSING

AGREEMENT FOR GOVERNMENTAGENCIES

To obtain driver histories via the Internet, you must:

ACCOUNTINFORMATION

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CHECKONE:	o FEDERAL	o STATE			o LOCAL
PARTA:MAIN OFFICE
Agency Name				Type of Municipality orAuthority					County
Contact Person			Telephone Number				Ext	Fax Number
StreetAddress (Physical Location)						City			State	Zip Code
MailingAddress (If Different)						City			State	Zip Code
Record StorageAddress (Physical location where records will be maintained for on-site inspection, review or audit by PennDOT or its representatives)
(If same as above, so state)
E-MailAddress					WebsiteAddress
EIN Number
			Are you a political subdivision of the Commonwealth of PA? o YES							oNO

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DL-9002(2-14)

PART B: Management

List name, title, phone number and driver license/identification card number (DL-ID) and the state issued of individuals participating in the direction, control or management of the organization. Attach if necessary.

PART C: Organization Description

Describe How Your Organization Will Use the DriverAbstract (be specific):

PART D: RequesterAccount History

Answer each question. If additional space is needed, attach a separate sheet with name and address as shown above.

1.	Has your organization previously applied for, had, or have an on-line account with PennDOT?
	o Yes	o No	If yes, enter the current/prior account number: _______________________________________
2.	Has your organization been subject to a PennDOT administrative action against a prior or current account?
	o Yes	o No	If yes, identify the type of action, the name of the person and/or business and the reason.
	____________________________________________________________________________________________
	____________________________________________________________________________________________
3.	Has your organization ever obtained Pennsylvania driver records through means other than the mail process?
	o Yes	o No	If yes, please list the name of the service you utilized and your account number.
	____________________________________________________________________________________________

4.If approved for Internet access to driver records, do you still plan to utilize other means to obtain Pennsylvania driver records, i.e. mail, approved service provider, messenger, etc.?

o Yes o No

If yes, please list what method you plan to utilize:______________________________________

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DL-9002(2-14)

PART E: User Name/Number and Password

After your account has been approved, you will receive two separate e-mails from PENNSYLVANIAINTERACTIVE LLC. One will provide your user name/number and one will provide your temporary password. Additional instructions on how to access your account will also be provided.

PART F: Affidavit

Yoursignaturebelowindicatesalltheinformationyouprovidediscorrectandthatyou,theapplicant(andemployees),have read and will comply with the following terms.

1.Requester will only perform searches of PennDOT records for the purpose stated on this application and each search will be in compliance with Section 6114 of the Vehicle Code, 75 Pa.C.S. § 6114, Limitation on sale, publication, and disclosure of records; Title 67, Pennsylvania Code, Chapter 95, Sale, Publication, or Disclosure of Driver, Vehicle, andAccident Records and Information; the Federal Driver’s Privacy ProtectionAct, 18 U.S.C., §§ 2721, et seq.; and the Federal Fair Credit ReportingAct, 15 U.S.C. §§ 1681, et seq.

2.Requester understands that the driver record is confidential and restricted information and will establish procedures to protect the confidentiality of these records.

3.Requester agrees not to sell, assign or otherwise transfer to any other party the information obtained from PennDOT.

4.Requester understands that PennDOTretains exclusive ownership of all driver record information provided and Requester agrees not to combine and/or link in with any other data on any database except as may be required by law.

5.Requester will not use the information received from PennDOT for direct mail advertising or any other type or types of mail or mailings.

6.Requester will not disseminate or publish on the Internet personal information obtained from PennDOT or allow any other person to disseminate or publish the personal information on the Internet without the express written permission of PennDOT.

7.Requester understands that he/she is responsible for all actions taken with their assigned commercial account number and password and will establish procedures to protect this information. Requester understands that he/she must contact PennDOT immediately if they feel their account number and/or password has been used by any unauthorized person or for any fraudulent or non-legitimate purpose.

8.Requester agrees that PennDOT, or an independent auditor selected by PennDOT, may audit their records as to their performance under this LicensingAgreement. The degree and conduct of any such audit, and the frequency of such audits, will be at the sole discretion of PennDOT and will focus on compliance with the terms of this Licensing Agreement. Requester agrees to fully cooperate with PennDOT auditors and agrees to be responsible for ensuring cooperation by any and all employees.

9.Requester understands that this agreement, account number and password may not be shared, transferred or sold to another party.

10.Requester will notify PennDOT in writing, within 10 days if there is any change in the information the requester has provided on this application. Requester will file a replacement application within 30 days of any such request by PennDOT.

11.Requester understands the Director, in and for the Bureau of Driver Licensing, may terminate this LicenseAgreement at his/her discretion. Reasons for termination include and are not limited to false statements made by the applicant, concealment of material facts in connection with this application, violation of any of the terms of this Licensing Agreement or for the convenience of PennDOT.

12.Requester understands that he/she must utilize Internet Explorer browser version 5.0 or higher with 128-bit encryption to perform online transactions. Requester agrees to limit the number of business transactions to 25 per session. Requester further understands that he/she must close their browser after each session.

13.Requester is responsible for all costs in obtaining access to PennDOT records under this Licensing Agreement. PennDOT shall have no liability whatsoever for payment for any costs associated with the implementation or continued operation of this Licensing Agreement.

14.Requester agrees that he/she will act in an independent capacity and shall not act or be deemed to act as an agent or employee of PennDOT.

15.Requester agrees to defend, hold harmless and indemnify the Commonwealth and its employees or agents from all claims, actions, damages, or losses which may be brought or alleged against them for my negligent, improper, or unauthorized use or dissemination of information provided by PennDOT.

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DL-9002(2-14)

16.Requester understands that they are bound by all terms and conditions of the Commonwealth website privacy and security policies that can be accessed through the following website links: http://www.portal.state.pa.us/portal/server.pt/community/policies_and_procedures/416

http://www.dot33.state.pa.us/about_site/index.shtml; http://www.dmv.state.pa.us/security/index.shtml.

17.Requester swears and affirms that the statements made herein are true and correct, and that any statement made on or pursuant to this form is subject to the penalties of 18 Pa C.S. Section 4903(a)(2) (relating to false swearing), which shall include punishment of a fine not exceeding $5,000, or a term of imprisonment of not more than two years, or both.

PART G: Certification Statement and Signatures

You must sign in the presence of Notary.

I certify under the penalty of perjury that I participate in the direction, control or management of our operations and that all answers and information contained within this form are true and correct.

SIGNATURE

TITLE

X

TO BE COMPLETED BY NOTARY

State of____________________________________County of __________________________________________

On __________________________, before me personally came __________________________________________

(Date)(Person(s) who signed above)

to me known and, who by me being duly sworn, deposes and says that he/she (check) ________works ______resides

at_______________________________________________________________________________________

(street address, city, state, zip code)

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