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Contact us
559 785-5645
Information Services Certification Of Agency
Commercial Requester Account Holder Information
Section 1
Please Check the Appropriate Box Below
(Required)
Business is a vehicle dealership licensed to do business in the state of California
Business is a manufacturer licensed to do business in the state of California
Please Print the following business information
Your Name
(Required)
Contact Person Name
(Required)
Street Address
Your City
Dealer/Manufacturer License Number
Dealer/Manufacturer Requester Code
Dealer/Manufacturer License Number
Dealer/Manufacturer Requester Code
E Daytime Telephone Number
(Required)
Address
State / Province / Region
ZIP / Postal Code
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY, THAT THE PARTY SPECIFIED BELOW IS AUTHORIZED TO ACT AS MY AGENT FOR THE PURPOSE OF OBTAINING INFORMATION FROM THE DEPARTMENT OF MOTOR VEHICLES PURSUANT TO CALIFORNIA VEHICLE CODE (CVC) §1808.23.
Hold the Department harmless from any monetary loss to the Department by reason of the use of information obtained from the Department by this agent; and Pay to the Department, its officers, and any other person(s) all civil damages occasioned to the Department or such persons by reason of the following acts or omissions by this agent: (a.) obtaining information from the Department by means of false or misleading representations, and/or (b.) selling, giving, or otherwise furnishing any information obtained from Department records to any third party not specifically authorized and approved by the Department.
OUR AGENT INFORMATION
Section 2
PLEASE PRINT THE FOLLOWING INFORMATION REGARDING AUTHORIZED AGENT
Your Name
(Required)
Contact Person Name
(Required)
Street Address
Your City
Dealer/Manufacturer License Number
Dealer/Manufacturer Requester Code
Dealer/Manufacturer License Number
Dealer/Manufacturer Requester Code
E Daytime Telephone Number
(Required)
Address
State / Province / Region
ZIP / Postal Code
CERTIFICATION
Section 3
CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
PRINTED NAME
EXECUTED AT
Your Country
(Required)
Your Country
First Choice
Second Choice
Third Choice
City
State
DATE SIGNED
(Required)
MM slash DD slash YYYY
SIGNATURE OF DEALER OR MANUFACTURER
Department of Motor Vehicles
Accounts Processing Unit - MS H221
P.O. Box 944231
Sacramento, CA 94244-2310
