Form Dl-9105 - Employment Affidavit Of Intended Use
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2DL-9105 (10-13)
Account Number:
EMPLOYMENT AFFIDAVIT OF INTENDED USE
INFORMATION SALES UNIT
(See Reverse Side for Instructions)
Business Type (check one):
q Individual
q Partnership
q Corporation
q Non-Profit
Legal Business Name: ______________________________________________________________________________________________________________
D/B/A Name (if applicable): ___________________________________________________________________________________________________________
Person Responsible: Name: ____________________________________________________ Title: _________________________________________________
Physical Address: __________________________________________________________________________________________________________________
City: _______________________________________________________________________ State: __________________ Zip: __________________________
Business Telephone: ____________________________________________
Fax No.: ________________________________________________________
E-mail: _________________________________________________________ Website Address: _________________________________________________
Federal Employer ID No.: _______________________
If Corporation, Date & State of Incorporation: _______________________________________________
Year Business Established: __________________
Dun & Bradstreet #: _________________________ U.S. DOT #: _______________________ (if applicable)
Location of Records: For departmental on-site inspection, audit and review purposes. o Check here, If address is same as above.
Street Address: _____________________________________ City: ____________________________________________ State: _________ Zip: ___________
Type of Business: _________________________________________________________________________________________________________________
Ownership: List below individual, each partner, or each corporate officer participating in the direction, control or management of the business. Attach list if needed.
Name (Last, First, MI)
Title
Date of Birth
Driver License
Day-Time
(MM/DD/YYYY)
STATE
Phone Number
1.
2.
3.
Please initial each statement below and sign at the bottom of the form.
______
1. I swear and affirm that any requested information will be used for employment purposes only.
______
2. I swear and affirm that I have on file a signed release for the subject of each driver record requested.
______
3. I swear and affirm that I understand the driver record is confidential and restricted information and I will establish procedures to protect the
confidentiality of these records.
______
4. I swear and affirm that I will not request driver information from the Department for personal reasons. (Examples of inappropriate access
or misuse of Department information include, but are not limited to: making personal inquiries on my own record or those of my relatives;
accessing information about another person, including locating their residence address, for any reason that is not related to my job responsibilities.)
______
5. I swear and affirm that the information obtained from the Department shall not be sold, assigned or otherwise transferred to any other party.
______
6. I swear and affirm that I understand that the Department retains exclusive ownership of all driver record information provided and no record shall
be combined and/or linked in with any other data on any database for any reason.
______
7. I swear and affirm that the information obtained from the Department will not be used for direct mail advertising or any other type or types
of mail or mailings.
______
8. I swear and affirm that I will not disseminate or publish on the Internet the personal information obtained from the Department or allow any
other person to disseminate or publish the personal information on the Internet without the express written permission of the Department.
______
9. I swear and affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this form is subject to
the penalties of 18 PA C.S. Section 4903(a)(2) (relating to false swearing), which shall include punishment of a fine not exceeding $5,000, or a
term of imprisonment of not more than two years, or both.
Subscribed and Sworn
to Before Me:
Mo.
Day
Year
S
Signature
Date
Signature of Person Administering Oath
E
Sign in Presence of Notary
A
L
Title
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Parent category: Financial