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SECTION E. ENTITY TYPE (Check the box next to the entity you are requesting information under and certifying to.)
Attorney - If you are a member of the Oregon State Bar, submit your bar number _________________ . If you are a
licensed attorney in a state other than Oregon, submit your state bar number _________________ and copies of
documents that prove you are a licensed attorney by the state in which you practice law.
Collection Agency - Submit a copy of your current registration certificate issued by the Oregon Department of
Consumer and Business Services.
Financial Institution - Submit a copy of your membership charter or your FDIC or NCUA insurance certificate.
I certify that I am an attorney, collection agency, or financial institution authorized under ORS 802.179 (4) to obtain
personal information from DMV motor vehicle records. Personal information I obtain will be used solely in connection
with serving a civil, criminal, administrative or arbitration proceeding in a court, government agency, or self-regulatory
body.
Government Agency - Submit your business card and your Federal Employer ID Number _________________ .
I certify that I am a government agency authorized under ORS 802.179 (1) to obtain personal information from DMV
motor vehicle records. Personal information I obtain will be used solely for carrying out this government agency’s
governmental functions.
Private Investigator - Submit your license number ____________________ issued by the Oregon Department of
Public Safety Standards & Training.
I certify that I am a licensed Oregon 0rivate )nvestigator authorized under ORS 802.179 (18) to obtain personal
information from DMV motor vehicle records. Personal information I obtain will be used for one or more of the
purposes outlined in ORS 802.179.
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Process Server - Submit copies of the documents or materials you are serving and proof that you are over 18 years
old (e.g.; copy of your driver license, birth certificate, etc).
I certify that I am a process server authorized under ORS 802.179(4)(b) to obtain personal information from DMV motor
vehicle records. Personal information I obtain will be used solely in connection with an existing civil, criminal,
administrative or arbitration proceeding, or a judgment in any court, government agency or self-regulatory body.
Insurer or Self-Insured Entity - Submit a copy of your current Certificate of Authority issued by the Insurance Division;
or submit a copy of your current Insurance License issued by the Insurance Division; or submit a copy of the
self-insured employer’s certificate provided by the Department of Consumer and Business Services or similar
certification as required by the state in which the employer is located.
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I certify I am an Insurer, Self-Insured Entity, or Insurance Support Organization authorized under ORS 802.179 (6) to
obtain personal information from DMV motor vehicle records. Personal information I obtain will be used solely in
connection with claims investigation activities, anti-fraud activities, underwriting, or rating.
Legitimate Business - Submit one of the following: s A Business License. s A Certificate of Existence or
Authorization issued by the Secretary of State; s A current copy of a Business Partnership Agreement; s A copy of the
business income tax form filed for the latest tax period for which filing was required; s A certification from the Office of
Minority, Women, and Emerging Small Businesses.
Or at least two of the following: s!BUSINESSINVOICEISSUEDBYTHEBUSINESSWITHINTHELASTTHREEMONTHSs!CURRENt
business card; s A copy of a signed contract for work performed within the last six months; s A copy of a current rental,
lease or purchase agreement or proof of ownership of the business premises; s A copy of a current rental or lease
agreement or receipt of purchase for business equipment; s A copy of a business related loan agreement; s A copy of
a current business advertisement.
I certify that I am a legitimate business authorized under ORS 802.179(3) to obtain personal information from DMV
motor vehicle records. Personal information I obtain will be used solely in the normal course of business for:
A. Verifying the accuracy of personal information submitted to the business: or
B. Correcting personal information submitted to the business, but only in order to:
1. Prevent fraud;
2. Pursue legal remedies against the individual who submitted the personal information; or
3. Recover a debt from, or satisfy a security interest against, the individual.
Note: You may not act as a third party to provide information to others. You must be the end user of the information.
735-7122 (8-23)
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