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INFORMATION SERVICES PROGRAM
GOVERNMENT REQU EST E R ACCOUNT APPLICATION DMVUSE ONLY
REQUESTER COOEI EXPIRAT ION DATE I TECH ID PART I APPLICATION
PLEASE PRINT CLEARLY IN INK OR TYPE
SECTION A. TYPE OF APPLICATION
CHECK ONE (1) BOX ONLY:
D Original -Complete ALL SECTIONS -OMV will assign Requester/Parking/Court Code.
D Change(s) to Existing Account -Complete Sections A, B and C, and all applicable sections where information is changing . Provide
signature in Part II, Section F. Provide current Requester/Parking/Court Code(s): __________________ _
[ii Renewal -Complete ALL SECTIONS -Provide current Requester/Parking/Court Code(s): 01652
IMPORTANT: TO AVOID PROCESSING DELAYS, PLEASE READ ALL INSTRUCTIONS PRIOR TO COMPLETING FORM .
SECTION B. AGENCY INFORMATION
1. NAME OF AGENCY
Fresno County ISD
2. DIVISION /PROGRAM THAT WILL REQUEST DEPARTMENT INFORMATION
3. AGENCY WEBSITE ADDRESS OR INDICATE "NONE"
http://www.co.fresno.ca. us /departments /isd
5. NAME AND TITLE OF THE PERSON FOR OMV CONTACT
Victor Luera; Brent Fremming
8. STREET ADDRESS (PHYSICAL LOCATION) STREET
333 W. Pontiac Way
9. MAILING ADDRESS OR INDICATE "SAME"
SAME
SECTION C. TYPE OF AGENCY
CITY
Clovis
1. CHECK APPROPRIATE BOX FOR THE TYPE OF GOVERNMENT AGENCY (CHECK ONLY ONE):
6. TELEPHONE
( 559 ) 600-7515
COUNTY
Fresno
10. RECORD STORAGE PHYSICAL ADDRESS
4 . FAX NUMBER
(559) 600-1480
7. E-MAIL ADDRESS
vluera @ fresnocountyca.gov
STATE ZIP
CA 93612
D Federal D State D City lZl County D Special District D Other: ____________________ _
DESCRIBE
2. IS THIS ACCOUNT BEING ESTABLISHED BY A GOVERNMENT ENTITY EXCLUSIVELY FOR USE BY ONE OF THE FOLLOWING?
D Yes , check appropriate box. [ii No, go to Section D.
CALIFORNIA APPLICANTS
D "Peace Officers" as described in California Penal Code §830.1 through 830.5. Identify Section #: ______________ _
D City Attorney prosecuting misdemeanor actions under Government Code Section 41803.5.
ANY STATE OR FEDERAL APPLICANT
D Attorney General D District Attorney D Public Defender D Public Defender's Investigator
D Government employees having statutory authority to carry firearms AND execute warrants AND make arrests. Identify Statutory
Authority; Code and Section#: ______________ ~------------------------~
SECTION D. PURPOSE OF ACCOUNT -Check one purpose only (Continued on Page 2)
t D
2. D
EPN (Employer Pull Notice) -Check this box if you are enrolling employees in the EPN program . For more information about the
EPN program and to obtain enrollment forms, go to www.dmv.ca.gov and "Search" for EPN General Information.
UPDATE AND INQUIRY -If your Agency is applying for authorization to update OMV records (i.e., courts, parking/toll, revenue recovery,
etc.), check this box. Explain the purpose of updating OMV records (space provided below):
a. D VehicleNessel Registration (VR)
PURPOSE OF UPDATE :
b. D Driver License/Identification Card (DL)
PURPOSE OF UPDATE :
DMVUSEONLY
Purpose Approved?
Dves D No
DMVUSEONLY
Purpose Approved?
Dves D No
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SECTION D. PURPOSE OF ACCOUNT (Continued from Page 1)
3. 121 INQU IRY ONLY -If your Agency is applying for authorization to request and obtain DMV record information in order to carry out
your governmental functions, check this box. Explain the purpose of inquiry below:
a. D VehicleNesse l Registration (VR) DMVUSEONLY
PURPOSE OF INQUIRY: Purpose Approved?
Pass-through only. Oves D No
Is residence address necessary to perform this function? Dves D No
b . D Driver License/Identification Card (DUID) DMVUSEONLY
PURPOSE OF INQUIRY: Purpose Approved?
Pass-through only. Oves D No
Is residence address necessary to perform this function? DYes D No
c. D Financial Responsibility (FR) -Available in paper/hardcopy only -DMVUSEONLY
See Instructions for more information. Purpose Approved?
PURPOSE OF INQUIRY: Dves D No Pass-through only.
Is residence address necessary to perform this function? DYes D No
d. D Occupational License (OL) DMVUSE ONLY
PURPOSE OF INQUIRY: Purpose Approved?
Pass-through only. Dves D No
Is residence address necessary to perform this function? DYes D No
SECTION E. ACCESS METHOD(S) -Check ALL That Apply
D Paper/Hardcopy -Manual Process (Allow 7 to 14 working days)
D Cartridge Tape (IBM Compatible, 3480 non-compressed or 3490 compressed) -Batch (Overnight plus mail time) -Renewals Only
D File Transfer Protocol (FTP) via Virtual Private Network (VPN) -Batch (Overnight)
121 On-Line -(Requires Network Connection) COMPLETE SECTION F.
D CLETS -If you are applying for a requester code in order to obtain access through the CA Law Enforcement Telecommunications
System (CLETS), check this box.
SECTION F. ON-LINE APPLICANTS ONLY -DO NOT COMPLETE FOR CLETS ACCESS
1 HOURS OF ON-LINE ACCESS:
Days Monday -Friday
2. NAME OF DATA CENTER (I.E ., DTS OR CITY/COUNTY DATA CENTER, etc.)
Fresno County ISD Data Center
NAME AND TITLE OF THE DATA CENTER TECHNICAL COORDINATOR
Brian Martin, IT Deputy Director
STREET ADDRESS (PHYSICAL LOCATION)
333 W Pontiac Way
MAILING ADDRESS (IF DIFFERENT)
3. NAME AND TITLE OF INFORMATION SECURITY OFFICER
Eric Matthews, IT Division Manager
NAME AND TITLE OF ACCESS CONTROL ADMINISTRATOR
Roland Olsen, IT Manager
STREET ADDRESS (PHYSICAL LOCATION)
333 W Pontiac Way
MAILING ADDRESS (IF DIFFERENT)
CITY
Clovis
CITY
CITY
Clovis
CITY
07:00 06:00 M Hours _________ A.M. TO ________ P ..
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TELEPHONE#
(559) 600-5800
TELEPHONE#.
(559) 600-5804
COUNTY
Fresno
COUNTY
TELEPHONE#
(559) 600-5810
TELEPHONE#
(559) 600-5837
COUNTY
County
COUNTY
DATA CENTER WEBSITE ADDRESS
www.co.fresno.ca. us
E-MAIL ADDRESS
bmartin@fresnocountyca.go
STATE ZIP CODE
Ca 93612
STATE ZIP CODE
E-MAIL ADDRESS
ematthews@fresnocountyca
E-MAIL ADDRESS
rolsen@fresnocountyca.gov
STATE ZIP CODE
CA 93612
STATE ZIP CODE
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PA RT II AGREEME NT -PLEASE REA D EAC H SE CTION CAR EFU LLY
A. GENERAL PROVISIONS
1. This Application/Agreement, hereinafter referred to as ':A.greement'; is between the State of California, Department of Motor Vehicles
(OMV), hereinafter referred to as the "Department'; and the Government Agency identified in Part I, hereinafter referred to as the
"Requester'; for the purpose of the Department providing information from its files for Government Agency use.
2. The term of this Agreement shall be for forty eight (48) months from the approval date and renewable at forty eight (48) month in tervals
thereafter.
3. This Agreement is subject to any restrictions, limitations, or provisions enacted by the California State Legislature which may affect the
provisions or terms set forth he rein. The Requester is required to comply with th e applicable statutes of the California Vehicle Code (CVC),
California Code of Regulations (CCR) Title 13, and United States Code Title 18.
4. No alteration or variation of the terms of this Agreement shall be valid unless made in writing and signed by both parties hereto. No oral
understanding or agreement, not incorporated herein, shall be binding on either party.
5. Requester shall not represent themselves as agents/employees of the Department. For the purposes of this Agreement, the "Requester"
includes the Requester's employees, unless the context provides otherwise.
6. (Applies to Federal Government and Out-of-State Agencies/Requesters)-"The Requester agrees to pay for any loss, liability or
expense, including attorney fees, expert witness fees and court costs, which arises out of or relates to the Requester's acts or omissions
regarding its obligations hereunder, where a final determination of liability on the part of the Requester is established by a court of law
or where settlement has been agreed to by the Requester. This provision may not be construed to limit the Requester's rights, claims, or
defenses which arise as a matter of law or under any other provision of this Agreement. This provision may not be construed to limit the
sovereign immunity of the Requester."
7. This Agreement is not assignable by the Requester, either in whole or in part, without prior written consent of the Department.
Ba. Any promotional or informational material related to accessing the Department's records shall be accurate and consistent with the terms
of this Agreement and shall only contain factual statements relating to the purpose and condition of access.
b. Requester shall not use the logogram IJI/" in any advertising or other agency business materials used in the business of the
Requester. Advertising shall neither staten~orTmply that there is any official connection between the Department and the Requester, or
that the Department has sanctioned or approved of either the advertisement or the Requester's service.
9a. If the Authorized Representative, designee responsible for the administration of the account, the OMV contact person, agency address,
or any other changes of information occur in Part I of this Agreement, notification shall be submitted, in writing, within ten (10) business
days on Government Requester Account Application (INF 1130) or Agency Letterhead to the following address:
Department of Motor Vehicles, Account Processing Unit-H221, P.O. Box 944231, Sacramento, CA 94244-2310
b. Requester shall notify the Account Processing Unit, in writing, (see address in 9a) within ten (10) business days of any intended or actual
closure of the Government Agency Requester Account.
B. INFORMATION USE
1. Requester shall not use Department records for any purpose except for that which has been approved by the Department in Part I.
2. When a non-law enforcement agency receives information from Department records that indicates a vehicle or vessel has a Department
of Justice (DOJ) "stop'; Requester shall immediately notify local law enforcement of its location, if known.
C. GENERAL SECURITY REQUIREMENTS
1. Requester shall maintain the security and integrity of the information it receives. A violation of any provision(s) of the Agreement, whether
by omission or commission, may result in suspension or termination of service to Requester.
2. Requester shall ensure compliance with all the security provisions of this Agreement. If misuse or inappropriate access is suspected or
confirmed, Requester shall notify the Department's Information Services Branch, Policy and Information Privacy Section, by telephone,
at (916) 657-5583 within one (1) business day. A written notification containing all facts therein shall be prepared by the Requester within
three (3) business days and mailed to the Department at the following address:
Department of Motor Vehicles, Information Services Branch, Policy and Information Privacy Section-H225, P. 0. Box 942890,
Sacramento, CA 94290-0890
3. In the event of any breach of the security of the Requester's system or database containing the personal information of California residents,
the Requester shall bear all responsibility for providing notice of the breach to the affected residents as required by California Civil Code
Section 1798.29. The Requester shall bear all costs associated with providing this notice. In addition, the Requester agrees to comply
with all federal and California state law, including all of the provisions of the California statutes and Title 13 of the California Code of
Regulations.
4a. Requester shall require every employee and the system administrator having direct or incidental access to Department records to sign
a copy of the Information Security Statement (INF 1128). The INF 1128 is required upon initial authorization for access to Department
records and annually thereafter. The Requester's signed statement(s) shall be maintained on file at Requester's work site for at least two
years following the deactivation or termination of the authorization and shall be available to the Department upon demand.
b. Requester shall restrict the use and knowledge of requester codes and operational manuals to employees who have signed an Information
Security Statement (INF 1128).
c. Requester shall maintain a current list of names of persons authorized to access Department records. This list shall be available to the
Department upon demand.
5. Access terminals and modems shall not be left unattended while in active session unless secured by a locking device that prevents entry
or receipt of information, or are placed in a locked room that is not accessible to unauthorized persons.
6. Video terminals, printers, hardcopy printouts, or any other form of duplication of Department approved records that are located in public
access areas shall be placed so that the records shall not be viewed by the public or other unauthorized persons.
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7. All information received from the Department's files must be dest royed once its legitimat e use has ended. The method of destruction for
t he Department's records will be conducive to the type of record requested and in a manner that cannot be reproduced or identified in
any physical or electronic form.
8. Requester shall not disclose its' Department assigned requester code, either orally or in writing, to anyone who is not in the direct employ
of the Requester and has not signed the Information Security Statement (INF 1128) other than a Department approved Service Provider
(Vendor or Agent).
9. Requester shall not sell, retain, distribute, provide or transfer any record information or portion of t he record information acquired under
this Agreement except as authorized by the Department.
D. RESIDENCE ADDRESS ACCESS AUTHORITY
1. Requester shall protect the confidentiality of any residence address received from Department records pursuant to eve §1808.47.
Requester's employees shall not obtain or use any confidential or restricted records for any purpose other than the reason set forth and
authorized by the Department.
2. Requester may release residence or mailing address information to an individual, other than an employee, who is acting on behalf of
the Requester provided an agreement acknowledging the confidentiality of residence address information pursuant to eve §1808.47 is
signed by the individual with whom the Requester has contracted services.
E. AUDIT
1. Requester's documentation supporting the reason for inquiry, including but not limited to, transaction details, and computer software/
programs maintained for the purposes defined in this Agreement, shall be subject to inspection, review, or audit by the Department or its
designee for a period of two years from the date of the request.
2. Requester agrees to accommodate Department's request for an inspection, review or audit immediately upon request from the department
or the department's representative and to allow on-site audits during regular business hours.
F. SIGNATURE REQUIREMENTS
I hereby acknowledge that I am an authorized representative of the agency named in Part I, Section B and have been designated as
the person responsible for compliance with the statutes and regulations pertaining to access and use of Department record information.
I have read and agree to the provisions contained herein and shall be responsible for the orientation , training, and supervision of persons
authorized to access Department record information.
I understand that false or misleading answers are cause for denial of an Agreement and/or termination of any access agreement granted.
I understand that if this application for requester account is approved, I will be required to conform to the statements presented within. This
Agreement specifies the terms and conditions of our relationship.Any deviations will be considered by DMV as misuse and may result in both
revocation of the account and refusal of subsequent applications. I understand that according to provisions of the California Vehicle Code
Section 1808.45, the willful, unauthorized disclosure of information from any department record for a purpose other than the one stated in
the request, or the use of any false report to obtain information from any department record, or the sale or other distribution of the information
to a person or organization not disclosed in the request is a misdemeanor, punishable by a fine not exceeding $5,000 or by imprisonment
in the county jail not exceeding one year, or both fine and imprisonment.
I understand that according to provisions of the California Vehicle Code Section 1808.46, any person holding a requester code who directly
or indirectly obtains information from the Department of Motor Vehicles using false representations or distributes restricted or confidential
information to any person or uses the information for a reason not authorized or specified in this application is liable to the Department of
Motor Vehicles for civil penalties up to $100,000 and shall have their requester code privileges suspended for a period up to five (5) years
or revoked.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
PRINT NAME AND TITLE OF GOVERNMENT OFFICIAL OR AUTHORIZED REPRESENTATIVE DAYTIME TELEPHONE NUMBER
Clovis, Fresno CA
CITY COUNTY STATE
PRINT NAME AND TITLE I DATE
SIGNATURE
x
WHERE TO MAIL YOUR APPLICATION AND SUPPORTING DOCUMENTS
ALL AGENCIES (Except Parking/Toll Agencies)
mail to:
Department of Motor Vehicles
Account Processing Unit-MS H221
PO Box 944231
Sacramento, CA 94244-2310
(916) 657-5564
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PARKING AND TOLL AGENCIES ONLY,
mail to:
Department of Motor Vehicles
Justice & Government Liaison Branch
Attn: Parking Coordinator-MS H171
PO Box 932345
Sacramento, CA 94232-3450
(916) 657-7732
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