HomeMy WebLinkAbout4663
Contract Number: 4663
Vendor:
LICENSING - DEPT OF (WA STATE)
Subject:
Public Disclosure - Internet Vehicle/Vessel Info
Department:
Muni Court
File Class:
LEG 12-1
Begin Date:
10/15/2007
End Date:
10/31/2008
Review Date:
02/15/2010
Vault Date:
01/01/2010
Comments:
..
INTERNET VEHICLENESSEL INFORMATION PROCESSING SYSTEM (IVIPS)
USER AGREEMENT BETWEEN
WASHINGTON STATE DEPARTMENT OF LICENSING
AND
BREMERTON MUNICIPAL COURT
Account # 780696
September 20, 2007
This Agreement is made and entered into by, and between the Washington State Department of Licensing,
herein after referred to as "DOL", 1125 Washington Street SE, Olympia, WA 98504 and Bremerton Municipal
Court herein referred to as "USER" 900 Pacific Ave Bremerton WA 98337.
1. PURPOSE OF AGREEMENT
This is a reimbursable services Agreement to provide public record information on vehicles and/or
vessels under Revised Code Washington (RCW) 46.12.370, RCW 46.12.380, RCW 46.12.390, RCW
42.56.070, http://apps.leq.wa.qov/rcw/, Washington Administrative Code (WAC) 308-93.087, WAC 308-
93-088, WAC 308-93-089, WAC 308-10, WAC 308-10-45, http://apps.leq.wa.qov/wac/ and Chapter
18USC Sec. 2721.;. -2725 Driver Privacy Protection Act (DPPA)
http://www.accessreports.com/statutesIDPPA1.htm. Executive Order 97-01
http://www.qovernor.wa.qov/execorders/eoarchive/eo97-01.htm. It is the USERS' responsibility to
become familiar with the above mentioned references.
This Agreement supersedes any prior Agreement for providing public record information as set forth
herein, known or unknown, rnade between DOL and' USER, and identifies the terms and conditions that
information is provided for inspection and copying.
SPECIAL TERMS AND CONDITIONS
THEREFORE, IT IS MUTUALLY AGREED THAT:
2. DEFINITIONS
As used in this Agreement, the following terms shall have the meaning below:
2.1 "Commercial purpose" means using or intending to use information for the purpose of facilitating a
profit-expecting business activity, except as provided in RCW 46.12.380.
2.2 "IVIPS" means Internet VehicleNessellnformation Processing System that is used to obtain
information under this Agreement.
2.3 "Personal Information" means information identifiable to any person, including, but not limited to,
information that relates to a person's name, health, finances, education, business, use or receipt of
governmentaLservicesor .otheL-activities, .add[esses,Jelepbor}e .1]l.Jmj:)~[~, ~Qgial. s~c;u.rity _ numbers,
driver license numbers, other identifying numbers or Protected Health Information, any financial
identifiers, and other information. that may be exempt from disclosure to the public or other
unauthorized persons under either RCW 42.56 or other state and federal statutes.
2.4 "Private Investigator" means a person who is licensed under RCW 18.165,
http://apps.leq.wa.qov/rcw/, and is employed by a private investigator agency for the purpose of
investigatioh; escort or bodyguard services; or property loss prevention activities.
2.5 "RGW' means the Revised Code of Washington.
2.6 "USER' means the primary agency or entity contracting with the Department of Licensing to access the
IVIPS data system.
2.7 "USERS"for the purpose of this Agreement shall include authorized employees with access to the IVIPS
_ -Hu.n--data=-system~jfoapplicable)..u-._._----_n, H ,_ ,,__. , _d, __ ,. H , " '. _
-------..--2~-"W}\C"mEiirns-WastiingtonAOminist(ative-Coae. .--~-----,----------,----.._---
3. PERIOD OF PERFORMANCE
Subject to its other provisions the Period of Performance for this Agreement, shall commence on the date
of execution, and shall not exceed October 31, 2008 or unless terminated, whichever occurs first.
NOTE: Before existing Agreement can be renewed, USER must submit a new application with current
business License (if applicable) and all applicable required documentation.
. This Agreement is void upon formal action of the State Legislature enacting statutory prohibition or failure
to provide funding for the performance of duties provided herein. .
IVIPS-K 8-20-07 ATF (2).doc
Appropriate Use Declaration, Attachment A
Page 1 of 10 . .
9/20/2007
4. . STATEMENT OF WORK
USER Shall:
Com I with and a rees to use the information rovided under this A reement for the sole ur ose of"
Verifying the accuracy of personal information submitted by the individual and for use by any
government agency, including any court or law enforcement agency, ,in carrying out its
functions, or any private person or entity acting on behalf of a Federal, State, or local agency
in carrying out its functions. If such information as so submitted is not correct or is no longer
correct, to obtain the correct information, but only for the purposes of preventing fraud by,
pursuing legal remedies against, or recovering on a debt or security interest against, the
individual. USER or USER employees shall not provide screen prints of the IVIPS records
to any clients, customers for any reason, even if the information is the clients, customer's
personal information. Clients and customers may apply for information through a publ(c
disclosure request to obtain their records from DOL. Providing a screen print may result in
termination of this Agreement.
lateAlIN numbers..--
-. . Re- iieistors initials.
S ecific reason for each search/in uir
T e of search/in ui hone, internet, or written.
4.8 Provide a legible copy of IRL to DOL for all USERS within three (3) business days of receiving a written
request from DOL. Failure to provide IRL as requested by DOL will result in immediate termination of
this Agreement
4.9 Receive information from DOL not exempt from disclosure promptly as stated in referenced RCW's and
WAC's to the extent that proper performance of its official duties and obligation is maintained.
4.10 Understand that data updates occur approximately every 48 hours for Vehicle and every seven (7) days
for Vessels. Inspection, copying, or inquiry fees may apply and be paid according to Payment & Billing
Section 5.
4.11 Request VehicleNessel records as authorized by applicable RCW's, WAC's, laws and statutes using
one of the following options:
. Option 1 - Telephone communication - DOL staff can provide verbal information, and receive
requests for copies of records to be sent to USE
IVIPS-K 8-20-07 ATF (2).doc Page 2 of 10
Appropriate Use Declaration, Attachment A
No variations or other uses are permitted and will be considered a violation and immediate termination of
this Agreement may occur.
4.1 Deposit a minimum of $25.00 or an amount determined sufficient to reimburse DOL for estimated
monthly services, before receiving any information. (See Payment & Billing Section 5).
4.2 Receive the USER's secure accounUaccess code from DOL. Each request for information will require
this accounUaccess code fr-om.USER and/or pH~-authorized USERS (employees) with accounUaccess
codes (if applicable).
4.3 Ensure each employee using IVIPS has reviewed and is familiar with this Agreement and signed the
Appropriate Use Declaration (AUD) form, Attachment A. The signed AUD form(s) shall be kept at
the USER place of business. DOL may request a copy of the signed form(s) at anytime.
4.4 Ensure the USER and USER'S employees and agents will maintain the confidentiality of the
VehicleNessel records by:
4.4.1 Protecting their account numbers and passwords;
4.4.2 Instructing USERS to change their passwords every 90 days, as recommended for security
enhancement and by using hard to guess passwords; particularly when there are changes in
personnel;
4.4.3 Instituting penalties for misuse of data.
4.5 Submit to DOL the names of employees(if applicable), who will have IVIPS access by completing the
User List form, Attachment Band,
. .405.:1-- .6achemployee-willbeissued.8 sub~accounUaccesscode._
4.5.2 Disclosure or unauthorized use of the sub-accounUaccess code by any USER is grounds for
immediate termination of this Agreement
4.6 Be responsible to notify DOL in writing of any changes to contact information within three (3) business
days of the change i.e. change of business address, phone number, Contract Manager, employee
eligibility or if an employee with access leaves employment. Failure to do so may result in immediate
termination of this Agreement. '
4.7 Maintain and instruct all employee USERS to maintain legible Information Request Log(s) (IRL),
Attachment C (i.e. each employee shall maintain a log)(photocopies of this sample form are permitted)
or USER may use a legible Information Request Log(s) (IRL), of the USERS choosing if the IRL
contains all of the followin
Date"Gfsear€hfin . wi
Account number
Time of search/in uir
9/20/2007
. Option 2 - Written Communication - DOL staff can provide a copy of a record or lists of individual
records as authorized.
. Option 3 - IVIPS - Provides the USERS the ability to inspect VehicleNessel records through the
internet.
4.12 Retain all information obtained under this Agreement for a period of five (5) calendar years from the
date of release by DOL, unless otherwise indicated by law. (Example: information received during
December 2007 may be destroyed January 2013). After the destruction of information USER shall
return to DOL a signed Certification of Data Disposition form, Attachment D, unless otherwise
indicated by law or USER is exempt as set forth in RCW46.12.380(6) or if the parties mutually determine
that return or destruction is not feasible
4.13 Acknowledge that whenever information is given to an Attorney or Private Investigator under this
Agreement according to RCW 46.12.380.
4.13.1 Notice will be provided by the DOL, to the VehicleNessel owner whom the information
applies, that the information has been granted by DOL to an Attorney or Private investigator
no later than the following business day.
4.13.2 When the USER is providing information to an Attorney or Private Investigator, the USER
must notify the VehicleNessel owner whom the information applies in writing no later than
the following business day, that the information has been granted to an Attorney or Private
Investigator
4.13.3 USER must also send a copy to DOL of the notice sent to owner by US mail no later than the
following business day addressed as provided in Section 17, Contract Manager.
4.13.4 All notices must include the name, address and phone of the Attorney or Private Investigator
requesting the information, and must include the Vehicle Nessel information provided
(i.e. Plate/REG and VIN/HIN).
4.13.5 Unless notification is otherwise indicated by law or if USER is exempt as set forth in RCW
46.12.380(6).
4.14 PROHIBITED USE OF INFORMATION
Unless otherwise required by law, any personal VehicleNessel owner information or part thereof
received through this Agreement by USER or USERS shall not:
4.14.1 Be furnished to any person, association, or organization without prior written approval from
DOL as provided in this Agreement.
4.14.2 Be disclosed, sold, published, or otherwise distributed, used for mailing purposes; or to make
unsolicited business contacts. For commercial purposes; for personal or private use for any
reason. "Unsolicited business contact" means a contact that is intended to result in, or
. .promotethesaleotany-goods oLservicesto a p.ersor) i1amed in th~. disgo~~d info.~rTla.ti.on.
4.14.3 Make false representation to obtain any personal information from an individual
VehicleNessel record from DOL.
5
PAYMENT AND BILLING
USER agrees to pay all fees due under this Agreement by one of the following methods:
.5.1 Depositintheamount of $25.00 via check or money order. Deposit is for pre-payment of DOL's
copying and direct costs for information.
5.2 Pay invoices received within fifteen (15) days of receipt. Billing shall be no less than monthly for
actual usage at the Fee rates set forth in this Agreement.
5.3 All correspondences must specifically state that money is for "IVIPS Deposit"; Payment shall be
made to: Revenue Accounting
IVIPS:Oeposlt-
P.O. Box 9048
Olympia, WA 98507
5.4 Upon termination of this Agreement, DOL shall refund any remaining portion of deposits received
after applying funds to any outstanding fee balances.
6 FEES
6.1 Telephone and Written
$ 0.15 - (fifteen cents) for each copy requested.
$ 0.75 - (seventy-five cents) for each page of microfilm or imaged document requested.
$ 1.50 - (one-dollar and fifty cents) for each certification affixed to any copy.
6.2 Internet
$0.04 - (four cents) for each internet inquiry. An inquiry means any access to the IVIPS that
retrieves a record or returns a "no file" indicated.
6.3 Lists
IVIPS-K 8-20-07 ATF (2).doc
Appropriate Use Declaration, Attachment A
Page 3 of 10
9/20/2007
Fees covering DOL's direct cost for computer-generated lists shall be agreed upon and pre-paid
before DOL will disclose the information.
6.4 DOL maintains the right to increase or decrease the fees for rendering services under this
Agreement. Any amended fees shall be subject to Section 10.
7 RIGHTS OF INSPECTION
DOL reserves the rights to monitor, audit, or investigate the use of VehicleNessel information collected,
used or acquired by the USER or USERS through this Agreement. The monitoring, investigating or
auditing, may include, but is not limited to, "salting" by DOL. "Salting" means the act of introducing data
containing unique but false information that can be used later to identify inappropriate access of internet
inquires and lor disclosure of record information obtained from DOL. If a USER is found to be in violation
of applicable RCW's, WAC's, laws and statutes cited in this Agreement, immediate termination may occur
and DOL may suspend and/or revoke the privileges of obtaining information for up to five (5) years.
Violations may result in gross misdemeanors punishable by a fine not to exceed $10,000 (ten thousand
dollars); or by imprisonment in a county jail not to exceed one (1) year or both for each violation.
S LIMITATION UPON ASSIGNMENT
This Agreement is not assignable by either party.
9 PROPRIETARY RIGHTS
USER shall acquire no proprietary rights, exclusive or otherwise, to information obtained from DOL.
10 AGREEMENT ALTERATIONS AND AMENDMENTS
This Agreement maybe amended' by mutual agreement of the parties. Such amendments shall not be
binding unless they are in writing and signed by personnel authorized to bind each of the parties.
11 ASSURANCES
DOL and the USER agree that all activity pursuant to this Agreement will be in accordance with all the
applicable current or future federal, state and local laws, rules, and regulations.
12. DATA DISPOSITION
Each party shall certify the return or destruction of all data sets as described herein upon expiration or
termination of this Agreement (Reference: Certification of Data Disposition, Attachment D) and shall retain
no copies. If the parties mutually determine that return or destruction is not feasible, neither party shall use
the Confidential Information in a manner other than those permitted or authorized by state and federal laws.
13. LIMITATION OF STATES L1ABILTY
The parties agree that in no event shall the state of Washington, the Department, the Director of the
peJJ9-"trl}~n! (JU~lIlyD~p<:lrt!l1e_llternpIQy_e~~,,~~JiClble JouU,~E:l3f(X any d,af!1ages, costs, lost production,. or
any other loss of any kind for failure of the Department's equipment, hardware or software fopertorm Tor '
any reason, or for the loss of consequential damage which is the result of acts of God, strikes, lockouts,
riots, acts of war, epidemics, acts of fire, failure of communications or computer equipment, facilities, or
software, power failures, nuclear accidents or other disasters.
The state of Washington, the Department, the Director of the Department or any Department employee
shall not be liable for any claim of any nature against USER bY any party arising from any failure in the
service furnished by the Department under this Agreement, for any errors, mistakes or acts on the part of
the Department or its agents which result in the failure of the Department's equipment or software which
fails to perform for any reason or for any other loss or consequential damage which is a result of acts of
God, strikes, lockouts, riots, acts of war, epidemics, acts of fire, failure of communications or computer
===-..- eq.tJjpDJ~Dt;:f9..QUjtie~;-::Qr:.~0ftW-9r~;:Row~r-f?ilqre~-;:nucle~1.dents--er-other-dis,?ste,.r:s".
14. DISPUTES
In the event of a dispute between the parties arising under this Agreement, which the parties themselves
cannot resolve, the dispute shall be referred to a dispute panel. The panel shall consist of one member
appointed by the Director of DOL, one member appointed by USER, and one member jointly selected by
both parties. The decision of the panel shall be final and binding upon the parties, unless the decision of
the panel requires either party to perform an illegal act. In the event the panel cannot resolve a dispute,
the aggrieved party may file a lawsuit. Venue of any lawsuit filed by any party against the other party
arising in whole or in part out of this agreement shall be in the Superior Court for Thurston County in
Olympia, Washington.
15. USER/USERS ACCESS TERMINATION
Each party may at its discretion disqualify a USER/USERS authorized by the other party from gaining access
to data. Notice of termination of access will be by written notice and may be sent via email, fax or United
States mail, and becomes effective upon receipt by the other party. Termination of access of one USER by
either party mayor may not affect other USER/USERS authorized under this Agreement. DOL shall review
IVIPS-K 8-20-07 A TF (2).doc Page 4 of 10 9/20/2007
Appropriate Use Declaration, Attachment A.
each termination on individual bases and has the final decision and reserves the right to terminate a
USER/USERS access without notice at its discretion.
Due to Chanqes
DOL may end this Agreement immediately without notice, at its discretion, in the event that a policy or
procedure change is implemented by DOL, or if applicable RCW's, WAC's, laws and statutes are
amended. Notice of termination of access will be by written notice and may be sent via email, fax or United
States mail, and becomes effective upon receipt by the other party.
16. TERMINATION
Default Any violation of the restrictions, conditions or requirements contained in this Agreement
constitutes grounds for DOL to end this Agreement immediately.
Convenience This Agreement may be ended by either party upon giving three (3) days written notice to
the other party; provided, either party may end the Agreement immediately for breach by the other party
of any of its obligations under the Agreement.
In the absence of actual delivery to, and receipt by either party by mail or other means at an earlier date
and/or time, notice of termination shall be conclusively deemed to have been delivered to, and received
by, the other party as of midnight of the third (3rd) day following the date of its posting in the United States
mail, addressed as provided in Section 17 herein.
17. CONTRACT MANAGEMENT
The Contract Manager for each of the parties shall be the contact person responsible for all
communications regarding the performance of this Agreement.
Bremerton Municipal Court
Theresa Ewing
900 Pacific Ave
Bremerton WA 98337
Phone: 360-473-5250
FAX: 360-473-5262
Email: theresa.ewing@ci.bremerton.wa.us
:",~ . .': '~','::'., ,,':, ,;;fr'<.' ,I~' ;'\~ .~:. :[\'~.':~.:, ." I);
. '""The- DOL ContraCt Mana e;-~is:~"
Eileen Boman
Department of Licensing
Vehicles Disclosure Unit
PO Box 2957
Olympia WA 98507-2957
Phone: (360) 902-3668
FAX: (360) 902-3827
Email: eboman@dol.wa.qov
--- ---18~rt\rF-6RJJlAffOt.rcoNTACi--- ___u m n____ - - ____u __ ._____ - ___ __n__ - un n__ --
The Agreement Information Contact for DOL is the Vehicles Public Disclosure Unit, (360) 902-3760 or
smitchell@dol.wa.Qov and shall be responsible for all communications regarding this Agreement relating
to:
.
Set-u Information and Questions
Account questions
..
.
Passwords
Other general information and/or questions
.
19. AFFIRMATION OF AGREEMENT
The parties signing below hereby affirm they have the authority to bind their respective parties to the
terms and conditions of this agreement.
}
Alan Haigh, FO
Contract Officer
APPROVED AS TO FORM ONLY
Siqnature on File Auqust 20. 2007
Jerry Anderson, AAG Date
Bremerton Municipal Court
~u9-D .
~re5A {4, tiu j f'\5 -l1ud-Sen.,;\as.u .
Print Name & Title
00,/2.4/07
Date
~
Contact Name: Theresa Ewing
)VIPS-K 8-20-07 ATF (2).doc
Appropriate Use Declaration, Attachment A
Page 5 of 10
9/20/2007
User List
MAIL OR FAX TO
PUBLIC DISCLOSURE
DEPARTMENT OF LICENSING
PO BOX 2957
OLYMPIA, WA 98507-2957
FAX (360) 902-3827
dt Li'cOE1NS11NijG
ATTACHMENT B
By signing this form:
1. I declare under penalty of perjury under the laws of the State of Washington that l agree to abide by all
applicable federal and Washington State statutes, rules, regulations, and policies under the IVIPS
Agreement.
2. I reviewed the IVIPS Agreement with each user listed below and they are eligible to use IVIPS, based on
the criteria established by the Department of Licensing.
3. I have obtained a signed Appropriate Use Declaration form from each emp/ovee and it is on file with;me.
DOL may request a copy of the signed forms at any time.
4. I am responsible to immediately notify DOL in writing of any changes to Agreement contact information i.e.
business address, phone number, Contract Manager, employee eligibility or if an employee with access
leaves employment. Failure to do so may result in immediate termination of this Agreement
~+On rrJuni c1Po.)tou.+
AGENCY/USER NAME
"ThereSA- A. lS-u'lnq
S~ISOR NAME (PR~NTED) -.-J
x~Q~.
SUPERVISOR SIGNATU E
BreYYlPl.-k"^~l.An;clfrJC{)uzt <Y1IZ4 /01
lOCATION DATE
IMPORTANT: PLEASE PRINT EMPLOYEE NAME
goo ~~~~'<-Ave..-
ADDRESS
1-'2>loo - ~/3 - ~ 2<..1L
SUPERVISOR PHONE NUMBER
~ 8C5 (ocr (0
PRIMARY ACCOUNT/ACCESS CODE
IDOL USE ONL Y1
1..]O.m~s DOGkr
PRINT EMPLOYEE NAME
:rU.d~€...
TITlE/POS ION
SUB-ACCOUNT NUMBER
2lhereSA- F..LU;Yl~
PRINT EMPLOYEE NAME
C cu.<2:+- See lJI'CJ2 s:. U ~ r .
TITLE/POSITION
SUB-ACCOUNT NUMBER
.. .--{'\...- - -- ._- - --. ._~---_._.._.- ------. -
3. t..)(::u..un UeJ s OJ'")
PRINT EMPLOYEE NAME
---n----T -._--- ._n.._._.____._..__<::::-;.:.~- - --
uga..\lec.h. ~~o-? -..
TITLE/POSITION
Pro~OY\OOJp. ,
TITLE/POSITION
SUB-ACCOUNT NUMBER
4. ~n C.J2>eJ1
PRINT EMPLOYEE NAME
5.~~ tl~Qn
PRINT EMPl YEE NAME
______6._~nn Ie.. G fO Ylt.YYlC1 n
----PRINT.EMPtOYEE-NAME-
SUB-ACCOUNT NUMBER
Lc~QI~CJ.1
TITLE/POSITION
SUB-ACCOUNT NUMBER
Lc..~~~/J:~~.__ _SOB;-ACCOtlNJ.:NtlMBEB,------------------
7. +kct+her~u'W-
PRINT EMPLOYEE NAME .
~~/]~\ T-LcYt
ITlE/POSITION
SUB-ACCOUNT NUMBER
8.
a Y'" I a.. p~'.o. S 2eK.
PRINT EMPLOYEE ME
u
\~c.n
ITlE/POSITION
SUB-ACCOUNT NUMBER
g. lJa n "3e.n b (\
PRINT EM YEE NAME
~
SUB-ACCOUNT NUMBER
1;TfnCA ~_00::l-S
PRINT EMPLOYEE NAME
Le3~/~oliLh
SUB-ACCOUNT NUMBER
*NOTE: This fonn may be duplicated.
IVIPS-K 8-20-07 ATF (2).doc
Page 7 of 10
c:.-.....I,....,..,... Ii...... ^..............h__"'...... D
User List
MAIL OR FAX TO
PUBLIC DISCLOSURE
DEPARTMENT OF LICENSING
PO BOX 2957
OLYMPIA, WA 98507-2957
FAX (360) 902-3827
dt LI'COENS'INnG
ATTACHMENT B
By signing this form:
1. I declare under penalty of perjury under the laws of the State of Washington that I agree to abide by all
applicable federal and Washington State statutes, rules, regulations, anp policies under the IVIPS
Agreement.
2. I reviewed the IVIPS Agreement with each user listed below and they are eligible to use IVIPS, based on
the criteria established by the Department of Licensing.
3. I have obtained a signed Appropriate Use Declaration form from each emp/ovee and it is on file with me.
DOL may request a copy of the signed forms at any time.
4. I am responsible to immediately notify DOL in writing of any changes to Agreement contact information i.e.
business address, phone number, Contract Manager, employee eligibility or if an employee with access
leaves employment. Failure to do so may result in immediate termination of this Agreement
'Brerre~r--kn ffiUf\ lupoJ ('ourt
AGENCY/USER NAME
:7fn(pf~~/::J
SUPERVISOR S'GNA~ .
Bl'~Uf))dp^1 QOUC+ ~1
LOCATION DATE
IMPORTANT: PLEASE PRINT EMPLOYEE NAME
900-Pa.6-hc,E1vR.
ADDRESS
RfPfnO f-6 'Y\.-JWA
9 g:ss I
\-3(00 -W,3 - S'2L{"2
SUPERVISOR PHONE NUMBER
I~DlO9 (p
PRIMARY ACCOUNT/ACCESS CODE
IDOL USE ONL yj
1. CLtve ~+On
PRINT EMPLOYEE N E
El-\ D Coom #
TITLE/POSITION
SUB-ACCOUNT NUMBER
2.JO~+.0 Ic::oYl
PRINT EMPLOYEE NAME
Tern,B\~~\kcY1-
TI LElPOS ON
SUB-ACCOUNT NUMBER
3.
PRINT EMPLOYEE NAME
TITLE/POSITION
SUB-ACCOUNT NUMBER
4.
SUB-ACCOUNT NUMBER
PRINT EMPLOYEE NAME
TITLE/POSITION
PRINT EMPLOYEE NAME
TITLE/POSITION
SUB-ACCOUNT NUMBER
5.
6. --~-
-PRINT'EMPLOYEE'NAME
SOB~KCCOUNLNOMBER
'f1'rtElP0SFfl0N
PRINT EMPLOYEE NAME
TITLE/POSITION
SUB-ACCOUNT NUMBER
7.
8.
TITLE/POSITION
PRINT EMPLOYEE NAME
SUB-ACCOUNT NUMBER
PRINT EMPLOYEE NAME
TITLE/POSITION
SUB-ACCOUNT NUMBER
9.
10.
PRINT EMPLOYEE NAME
TITLE/POSITION
SUB-ACCOUNT NUMBER
*NOTE: This form may be duplicated.
IVIPS-K 8-20-07 ATF (2).doc
Page 7 of 10
dt LI'CiENS1rNG
ATTACHMENT C
INFORMATION REQUEST LOG
(IRL)
MAIL OR FAX TO
PUBLIC DISCLOSURE
DEPARTMENT OF LICENSING
POBOX 2957
OLYMPIA, WA 98507-2957
FAX (360) 902-3827
Each USER is required to maintain a legible Information Request Log (IRL) for all requested information.
USER shall provide a legible Information Request Log, upon written request from DOL within three (3)
business days of USER's receipt of such request, with the exact purpose for which any personal
information provided under this contract was used. Failure to provide requested information to DOL will
result in immediate termination of this Agreement and other sanctions authorized under RCW 46.12.390.
(Photocopies of this form are permitted).
Bremer4-o0mUf) 1 .Qt.l
AGENCY/USER NAME
/80 lDq (01
USER ACCOUNT/SUB-ACCOUNT NUMBER
IMPORTANT: Please print legibly
Date Of Time Plate I VIN Requestor EXACT PURPOSE Type of
Search Initials Specific Reason for Search/lnquiry Inquiry
1 o Internet
DPhone
DWritten
2 Dlnternet
DPhone.
DWritten
3 Dlnternet
DPhone
DWritten
4 Dlnternet
DPhone
DWritten
5 Dlnternet
DPhone
DWritten
6 Dlnternet
DPhone
DWritten
7 Dlnternet
_____c __ ._~- ----"- ._~-+_._--- .. - - - - -- --- --- ------- --~._-- -------- -~- - ---- ----------- -- -- -- ----- ----~--- ..[JPJlOne____
- -...---.. --- -~ - - -- ------ --------- -- .----
DWritten
8 Dlnternet
DPhone
DWritten
9 Dlnternet
DPhone
DWritten
10 Dlnternet
DPhone
DWritten
11 Dlnternet
-- .I]Phone ~ .~
-E1Wrltten
12 Dlnternet
DPhone
DWritten
13 Dlnternet
DPhone
DWritten
14 Dlnternet
DPhone
DWritten
15 Dlnternet
DPhone
DWritten
IVIPS-K 8-20-07 ATF (2).doc
Information Request Log, Attachment C
Page 8 of 10
9/20/2007
INFORMATION REQUEST LOG (IRL)
B,Urerlo f\ m U f\ ). Qj-: t
AGENCY/USER NAME
1801.0<=1 iD (
USER ACCOUNT/SUB-ACCOUNT NUMBER
IMPORTANT: Please print legibly
Date Of Time Plate / VIN Requestor EXACT PURPOSE Type of
Search Initials Specific Reason for Search/Inquiry Inquiry
Dlnternet
DPhone
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Dlnternet
DPhone
DWritten
Dlnternet
DPhone
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Dlnternet
DPhone
DWritten
Dlnternet
DPhone
DWritten
Dlnternet
DPhone
DWritten
Dlnternet
DPhone
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Dlnternet
DPhone
DWritten
Dlnternet
DPhone
--,-~-- .. DWritten
. u --- - - .. .-. --- -- - E1lnternet--- -----------
DPhone
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Dlnternet
DPhone
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Dlnternet
DPhone
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Dlnternet
DPhone
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-- -- ,- - -..----.-. ..- .. . . B!nternet ---.
DPhone
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Dlnternet
DPhone
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Dlnternet
DPhone
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DPhone
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Dlnternet
DPhone
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* NOTE: This Form may be duplicated
IVIPS-K 8-20-07 ATF (2).doc Page 9 of 10
Information Request Log, Attachment C -Continued
9/20/2007
dt ti'C'ENSIN'c;
ATTACHMENT D
CERTIFICATION OF
DATA DISPOSITION
RETURN THIS FORM TO DOL'ONLY AFTER DISPOSING OF DATA
Date of Disposition Account No.
Data disposition methods used upon expiration or termination of this Agreement: (select all that apply).
C8J CHECK THE APPROPRIA TE BOX(ES)
D All copies of any data sets related to this data sharing Agreement have been wiped from all data storage
systems and media.
D All on-line access accounts related to this data sharing Agreement have been deleted.
D All printed and hard copy materials and all non-wiped computer media containing any data related to this
data sharing Agreement have been destroyed.
D All copies of data sets related to this data sharing Agreement that have not been disposed of in a manner
described above.
D Parties mutually determine that destruction is not feasible.
D EXEMPT as set forth in RCW 46.12.380 (6).
I declare under penalty of perjury under the laws of the State of Washington, by my signature below that
the data disposition requirements have been fulfilled as indicated above.
USER Business Name
Business Address
Date
. Signature
Print Name
. J:itle
Location Date
RETURN THIS FORM TO DOL AFTER DISPOSING OF DATA
MAIL OR FAX TO:
PUBLIC DISCLOSURE
DEPARTMENT OF LICENSING
PO BOX 2957
OLYMPIA, WA 98507-2957
FAX (360) 902-3827
IVIPS-K 8-20-07 ATF (2).doc
Data Disposition form, Attachment D
Page 10 of 10
9/20/2007
09/2[3/~~0B~r i 1~~: 03
36(14735'262
BREMERTON MUNI
PAGE 132
_11II IIAmll~GtDR !lATE otl:ARl'MEN~ ot
Cf:&.i LICENSING
Vehicle I Vess~el DisclosU"E~
Agreement Applicatio,l!'a
PUSI..IC OISCl.OSURE SECTION
P.O; BOX 2957
OLYMPIA. WA98507-2957
(360) 902-3760 .
FAXi (360) 902-3827
We will only release personal, identifying information to YIDU, as allowed by Washington State and F;ederal
.. laws, to cornplete work in 'the normal course of your business. Please complete the form and sign on
page 2> Use additional sheets if necessary. .. . .... . q (0.. . .
. ISb\' ... .~
PLEASE PRINT .
COMPANy I p,{'leN(;'I' NAME; .
fu(rW...i-+~f\ mlAn i c...i..Q'^! c..t3urt
MAILING ^DCIRES~I. . . . ~ (;ITY
ooJ'a d A c:.. A~. {5r(.J'J")(.r+o n
EMAlLAODAESS IF' AVAILABLE . . .. ..
Th~r-("5~. Eu~ 1 "5@ tJ ~ B'r~n.. V\I A . u.:-3
1. SPECIFIC T't'P'I: OF.INFORMATIONREQUESTEO;
. ... (~j:~h.u&>req" s~~d'~lJ)ru.f ,'tpr;t v ,'w
lJ~~l~rrl(ctJ..an l'or ~~ C\ t:lct.i~ .
.~
PHONE NUMB!!!!
(~CDC)") ~.'73- ~2. ~O
FAXNVM~i;, ;.,
(~b)q...,~- S'L<o2...
: . .~- ,
Srl~i'E Zlf;-"CCIDE:
WA c~~a::ro,
. i ' , !
t{.'3\'Sh:r.eJ oWhU"
2.I:XPLAIIN :IN DETAIl, THE. RE.GiSON(S) YOU NEED THE INFORMATION AND HOW YOU WILL U'SE IT:
lAJh.l~n ?OJ"~ c..~ ~cue W\;lOd) ,.we....O.JIi!.onLt} prt>'{,~
0. tUD"C~;.:..~~~~nrrr--n_'.- .
________ ______.l.Of'clLm(.cLian~L_l.0n~!~L~-~~"!:~~~,-~~~~~lt~ _~_~~_ ~~. :.__~...~-'-__ ~.__ _.__'
()U.:l\'\R...V" "\).)~ -tIki. c.:~ U,)CI.D ~~ I we 1..JX:)\,.d~ ,tU.A~ ~ ..r: :'. .'
P~~\OO~ b~.ri n-forrna::L.~ . --rtu:.o lhfo~"'~. lJ.'ould b..{
'~l~ fd~ c..ourt i..nfor~O\"1 ~'-'O' . ".
_.........---~--
3, WILL. YOtJ:.Grv'~iHE PEI~SONAL RECORD INFORMATIOt~ TO ANYONE E;LS~;?
NO]!in . 'r~s 0 (iF= Vr:S; EXpLAIN TO WHOM AND WHY)
. .
-----
4. WILL, YCIU CONTACT TH/~ OWNER(S) OF RECORD? 0 NO BI YES .(IF YES EXPLAlt'J HOW AND WHY)
Wl~ wouJd Stnd ~ p~lin~ ci~ OY' coltLC"h 0(') n()h.~ .
~ ~ 1 tOT ~ r~9\.5tvAo& 0 WN. r 50 t-huj, CcI..n ~ t"r\o.t:U.
CUJu~" o-f ~ur..-~ CO\),,"-1:-o..ctl on 0f"I ~ vth.l:c.L.....
TI1-42I>-500 (lWIOG) YI ""oR j '" 2
09/20/2007 12:03
35EI4735252
BREMERTON.MUNI
PAGE 03
PUEASE CHECK ALL THAT APPLY AND FOLLOW THE SPI::CIFIC INSTRUCTIONS
o I re!prosenl a businessl. " '. . '. " . '. .
· Provide a copy of the unexpired business license. If your business, is not requtred to be lioensed
. in this state, yom Federalemployer identification number/Fed~wl:11 :lax number (or Uniform :
t;3usiinelss Identifier) (In officillll rel1tl!rheadwlth a notari~~ed siigl1GIlure of the owner o~;an I .
authorized representative, will be required.. ~'
[J f am anatt;orney , . ' .
. .. Provide a copy of your unexpired business license orbal' card.
[J I am a prlvatEl InvestiSJatol' . " ",
, .. Pro'lidl!.3 copy of your private investigator license. '
. ,
. ,
~~ I repj"'ll~e~fl a gcvelrnmelll'l agency, . . . .
. . ':- Pnnts!;1encynamB: 8remJE/l~ilmUn\~J.. ,1C6ur-r .' .
'D I reprElSen1t a non-prolfit cllrganlzatlon .' .' '....;..
, . · Provide a copy of the! Articles of Incorporation, flied wittlthe SHci'etary of State, or a copy of Tax .
, '.,: Exempt Statusjrrom the' Internal Revenue Servioe [501 (c)(3)]. .,'.. ' .
ALL AF~PL'CA"IONS ARE REVIEWED ACCORDING TO STATE ANO FEDERA,L DISCLOSURE LAWS.
WE WllLll. RlESI:l.ONDTO YOU WITHIN FIVE 'BUSINESS DAYS FOLl.OWING THE RECEIPT OF YOllA
APPLrCA,TION.
Agreement to pl'otect information and lists of individual!l including fr.f?n1I use for a commerci~1 pu.rp~.se
Except as provldecl for In 18 USe Sec. 2721 (DPPA),RCW 46.12.370, 46.12.380 an~l WAC 308-93-087, I hereby ~gree
that tl1e information provided to me by the Department of Licensing' shall not be divuli!;led to any thirdParty:T'i)~1 :1,..'
information wiill not be used for ~~ny purpose other than stated on this application, 01' for commercial purpoi~e ~)' any o~ner
individual or otganfz8tion I represent. I will not use, or facilitate the use of. the inforrtn,ticm for the purpose of ma.king any
unsolicited business contact with a peIrson named in the disclosedinformatiol1. .
. .
"declare L.lIOdElrp6rlalty of perjury und,er the laws of the State of Washington that all c~f the information on this application
~_____j!LtrY~cancL~ITect.______.___________~__~_~~_~__-;___~________________________________~._~_
:ni'e.ri~..e.....ll...rJ..ul nCJ 'O~ \-20,\ 0,
fI" E9TEA'S Nj\M~iPtEI\SE,PR1NT) ,~ DA'~i:
~ L' 2~:"'. (lour+ Sen.l!u.s){a.f1"-3.u- D"I \ 20\ <:):]
aUI1STl1R'S SI?N"~IlE '. . " . D^TE
. . )
, "
. '
PLEASE MAIL OR FAX COMPLETED APPLICATION AND!mpPORTrNGi [II04~UMENiATION TO::
. I 'I. ' " .' , '>,.::
DEPAR'TMe:NTpF LICENSING ' '. . . . , '
ATTIN PUB:LIC DISCLOSURE . .
POI sOX 2957.
OLYMPIA WA ~8507.2957
(360) 902-3781) .
FAX # (36(11) 9~2~3827
I
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TO.42o.S30 (fllM16) W Pllll8 2 Of 2
. ,
. , ,
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The Depsrtment of Licensing has B policy C~, pr,oviding 'equal access, teJ.lts seritl~. '
If you need special accommodation, ples~le 1~1I (360) 902-3600 or TTY (360) 884-88$5,