Servico, Inc. - DMV Form

Costs:

SEARCH $50.00

RUSH $15.00

DISBURSEMENT TO DEPT. $10 per doc $10.00

ADMINISTRATIVE HANDLING $5.00

Subtotal

ADDITIONS?

Email/Fax

Shipping (see pricing below)

YOUR TIME FRAME

Routine

Rush + $15

Your information:

Date:

Your Name:

Firm Requesting Information:

Firm Address:

Your Phone:

Your Fax:

Your Reference No:

FILL IN THE APPROPRIATE INFORMATION FOR CONDUCTING SEARCH:

Leave blank fields for unknown info

Please call if this is not a NYS Search

Name of Driver:

DOB:

Address of Driver:

Driver License Number:

Plate No:

Registered Owner:

Registered Owner Address:

VIN:

Year and Make of Vehicle:

Ticket, Case Or Order Number:

Date of Violation/Accident:

County:

Effective date of doc requested:

Offense:

Please indicate search(es) requested by checking the appropriate box(ES)

Drivers Abstracts

Computer

Certified

Plate Registration Check

Computer

Certified

Lien Title Search

Computer

Certified

Insurance Search

Computer

Certified

*Computer Searches Take 1-2 days, certified up to 2 weeks*

Operator Report

Police Report (# ) (accident report # ) (above, min. $50+tax) (MV15) (MV19SC)

Copies

Suspension Revocation (Order#,date

Registration Application (MV15)

License Application (MV15)

Insurance Certification re:date of accident

Other-Delivery/Research/etc.

Your Instruction to Us for Handling

(Regular Mail will be used unless otherwise marked)

Fax Prior to mailing ($10 fee)

Federal Express ($25 fee), Account No.

Use our account number ($25 fee)

Special Instruction:

**** PLEASE NOTE FEES WILL BE CHARGED WHETHER THE REQUESTED INFORMATION IS AVAILABLE OR NOT

With respect to information to be obtained from the records of the New York State Department of motor Vehicles, please check the use or uses for which the information is requested, sign and date This inquiry at the bottom, and return to Servico Inc.

1. For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person or entity action of behalf of a Federal, State, or local agency in carrying out its functions.

2. For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

3. For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only (a) to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; and (b) if such information as so submitted is bot correct or is no longer correct, to obtain the correct information, but only for purpose of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual.

4. For use in connection with any civil, criminal, administrative, or arbitral proceeding in any Federal, State, or local court or agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or pursuant to an order of a Federal, State, or local court.

5. For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, redisclosed, or used to contact individuals.

6. For use by any insurer or insurance support organization, or by a self-insured entity, or Its agents, employees, or contractors, in connection with claims investigation activities, anti fraud activities, rating or underwriting.

7. For use in providing notice to the owners of towed or impounded vehicles.

8. For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection, (Licensed private investigators or investigative agencies certified by the Utah Department of Public Safety).

9. For use by an employer or its agent or, insurer to obtain or verify information relating to a holder of a commercial driver's license that is required under the Commercial Motor Vehicle Safety Act of 1986 (49 U.S.C. App. 2710 et seq.).

10. For use in connection with the operation of private toll transportation facilities.

11. For any other use in response to requests for individual motor vehicle records if the motor vehicle records if the motor vehicle department has provided in a clear and conspicuous manner on forms for insurance or renewal of operator's permits, titles, registrations, or identification cards, notice that personal information collected by the department may be disclosed to any business or person, and has provided in a clear and conspicuous manner on such forms an opportunity to prohibit such disclosures.

12. For bulk distribution for surveys, marketing or solicitations if the motor vehicle department has implemented methods and procedures to ensure that individuals are provided an opportunity, in a clear and conspicuous manner, to prohibit such uses; and the information will be used, rented, or sold solely for bulk distribution for surveys, marketing, and solicitations, and that surveys, marketing, and solicitations will not be directed at those individuals who have requested in a timely fashion that they will not be directed at them.

13. For use by any requester, If the requester demonstrates it has obtained the written consent, of the individual to whom the information pertains.

14. For any other use specifically authorized under the law of the State that holds the record, if such use is related to the operation of a motor vehicle or public safety.

Please Note: With respect to the above referenced information obtained from the records of the New York State Department of Motor Vehicles, and to the extent that the said information contains personal information as defined by §§2725(3) of the FEDERAL DRIVER'S PRIVACY PROTECTION ACT, 18 U.S.C. Section 272 et seq., SERVICO, INC. Hereby conveys said Information to the REQUESTER pursuant to the express or Implied representation and warranty of REQUESTER that REQUESTER has requested said information and accepts same on the condition that said information will not be used for any purpose expressively permitted by the said FEDERAL DRIVER'S PRIVACY PROTECT ACT. By accepting the said information, REQUESTER agrees to indemnify and hold harmless SERVICO, INC. from any and all claims and liabilities of whatsoever nature that may be made against SERVICO, INC., and to pay all expenses, including reasonable costs and attorney fees, that may be Incurred by SERVICO, INC., as a result of or arising out of or in any way connected with the misuse of or unlawful disclosure of the information provided to REQUESTER.

contact information:

Your Name:

Your Firm:

Email:

Your Phone:

Your Fax:

How would you like to be contacted:

Billing information:

Address:

City:

state:

zip:

Shipping Information:

Address:

City:

state:

zip:

SEARCH $55.00

RUSH $15.00

DISBURSEMENT TO DEPT. $10 per doc $10.00

ADMINISTRATIVE HANDLING $5.00

Subtotal