Form Os/ds-19 - Application For On Line Access To Motor Vehicle Records Page 5
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7CERTIFICATION OF APPLICANT
READ THE BELOW DRIVER PRIVACY PROTECTION ACT. INITIAL NEXT TO THE NUMBER(S) OF THE LAW
THAT APPLIES TO YOUR SPECIFIC USE OF THE MVC RECORDS AND SIGN/DATE THE CERTIFICATION
USES PERMITTED BY N.J.S.A. 39:2-3.4(c)
___________ For use by any government agency, including any court or law enforcement agency 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.
___________ 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 the removal of non-owner records
from the original owner records of motor vehicle manufacturers.
___________ For use in the normal course of business by a legitimate business or its agents, employees or
contractors, but only:
1. to verify the accuracy of personal information submitted by the individual to the business or its agents,
employees or contractors; and
2. 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.
___________ 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 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.
___________ 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.
___________ 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, antifraud activities, rating or underwriting.
___________ For use in providing notice to the owners of towed or impounded vehicles.
___________ 8. 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," 49 U.S.C. App. §2710 et
seq.
___________ For use in connection with the operation of private toll transportation facilities.
I hereby certify that the foregoing statements and submitted list(s) are true to the best of my knowledge. I understand
that i f an y of t he s tatements or s ubmitted l ist(s) ar e w illfully f alse, I am s ubject t o puni shment. I hav e al so r ead t he
“Driver’s Privacy Protection Act” N.J.S.A. 39:2-3.4(c) and I have initialed all that apply to my request for online access
and that I will only use any personal information contained in records I have requested as permitted by the Act.
Name and Title of Authorized Company Representative
Name of Company (please print or type)
(please print or type)
Signature of Authorized Company Representative
Date
(Original Signature Only. No Stamp Signature)
OS/DS-19 (R9/11)
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