Request for Motor Vehicle Administration Records DR-057 (0-1) My signature acknowledges, under penalty of criminal prosecution, that I will use information received from the Motor Vehicle Administration (MVA) solely for the purpose I describe on this application, and further agree that I will not release personal information obtained from MVA records except as permitted by Title 4 of the General Provisions Article (Maryland Public Information Act). I understand and acknowledge that by requesting information from Motor Vehicle Administration records I have read and agree to the terms of the MVA Privacy Protection Agreement on the reverse side of this form. I also acknowledge that I have read the Notice of Appeal Procedure also set forth on the reverse side.Signature: þ þ Printed name: þ þ Date: þ þ þ Please complete all requested information as applicable. MVA Use Only: þ 036036 036 036 036Credit Card 036 Type of Record: þ þ information for CDL holders)-Subject of Record:also request a PBJ driving record.Name:DOB: Status:Attorney driving record of your client)Attorney222s Signature:Employer: Employer222s Signature:Printed Name: Requestor Information:Name: Please complete this section if record is to be mailed. Please print or type information.Full Name:City:State:Zip Code: (MVA Use Only): Name: Name: Purpose of Request: 6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575. American LegalNet, Inc. www.FormsWorkFlow.com Apply to register to vote with your driver222s license transaction. For details ask your customer agent. to Vote Now!Apply to... MVA Privacy Protection AgreementUse of information obtained through this Request is governed by Federal and State laws. It is the responsibility of the Requestor to insure that all use of information obtained through this Request complies with all applicable Federal and State laws.employer and employees: Understand that federal laws affect access to and use of computer information, including, but not limited to, 15 U.S.C. 247 271et seq. (National Institute of Standards and Technology); 44 U.S.C. 247 3541 et seq. (Federal Information Security ManagementAct of 2002); 49 U.S.C. 247 30301 et seq. (National Driver Register Act of 1982); 5 U.S.C. 247 552 (Freedom of Information Act);5 U.S.C. 247 552a (Privacy Act of 1974); 18 U.S.C. 247 1030 (U.S. Computer Crime Statute of 1984); 18 U.S.C. 247 1001 et seq.(Computer Fraud and Abuse Act of 1986); 17 U.S.C. 247 109 (Computer Software Rental Amendments Act of 1990); 15 U.S.C. 2471681 et seq. (Fair Credit Reporting Act); and 18 U.S.C. 247 2721 et seq. (Driver222s Privacy Protection Act of 1994).and their customers also adhere to State data processing security policies as set forth in Executive Order 01.01.1983.18 (Privacyand State Data System Security); Md. Code Ann., Criminal Law Article 247 8-606 (Making false entries in public records and relatedcrimes) and 247 7-302 (Unauthorized access to computers and related material); Md. Code Ann., General Provisions Article, Title 4(Maryland Public Information Act); and, as published by the Secretary of the Department of Budget and Management from timeto time under Md. Code Ann., State Finance and Procurement Article, Title 3A, Subtitle 3 (Information Processing).result of their access to personal information from motor vehicle records. Are familiar with all provisions of the federal Driver222s Privacy Protection Act of 1994, 18 U.S.C. 247 2721 et seq., and with Title 4 ofthe General Provisions Article (Maryland Public Information Act), and 247247 12-111 through 12-113 of the Transportation Article,Annotated Code of Maryland, which limit access to personal information from public records in Maryland. The Requestor onbehalf of itself, its successors and assigns further agrees that all users will abide by the terms of both the federal and state lawincluding, but not limited to, those restricting access to personal information from Motor Vehicle Administration records only tothose persons and for those purposes which are permitted under both laws.purpose for which the personal information is to be used; and, to make that record available to the Motor Vehicle Administrationupon request. Shall be liable for, and shall indemnify, defend and hold the Motor Vehicle Administration harmless for any misuse ormisappropriation of any personal information in a record obtained from the Administration in connection with this Agreement,including, without limitation, reasonable attorneys222 fees and all other costs of litigation. Shall further indemnify the Motor Vehicle Administration for and against any and all losses, damages, judgments, liabilities, orsimilar costs and expenses which arise in whole or part out of acts or omissions by the client with respect to laws restrictingaccess to and disclosure of vehicle records including, without limitation, reasonable attorneys222 fees and all other costs ofdefending against such action or claim. Notice of Appeal ProcedureGeneral, pursuant to GP 247 4-1B-01, et. seq. You may also pursue judicial enforcement under GP 247 4-362 of the Maryland Public Information Act. (Copies of the law available upon request.)Reverse American LegalNet, Inc. www.FormsWorkFlow.com