Fillable Form 4678 - Request For Security Access Code (Page 2 of 2) in pdf

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SECTION C. CURRENT OR PREVIOUS ACCESS TO RESTRICTED INFORMATION

Has Requester, or any partner, officer or member thereof, ever had, or currently have, a Missouri Security Access Code for the purpose of

accessing restricted information?

Yes

If yes, indicate the current or prior Security Access number or requester code(s): ______________________________

SECTION D. GENERAL SECURITY REQUIREMENTS AND TERMS OF ACCESS.

REQUESTER UNDERSTANDS AND AGREES AS FOLLOWS:

1. Requester shall maintain the security and integrity of the information received. A violation of DPPA or of any provision set forth herein,

whether by omission or commission, shall be grounds for action by the Department and may result in termination of the security

access code.

2. Requester shall ensure compliance with all security provisions set forth herein. If non-compliance is suspected or confirmed, the Requester

shall immediately notify the Department by telephone at (573) 751-2633. Requester shall prepare and submit within three business days

a written notification of any such non-compliance to the Department at the following address: MISSOURI DEPARTMENT OF REVENUE,

GENERAL COUNSEL, PO BOX 475, JEFFERSON CITY, MO 65105-0475.

3. Requester shall maintain a current list of persons and entities authorized to access Department record information, or to whom such

information may be disclosed. This list shall be available to the Department upon request.

4. Requester shall not use, sell, retain, distribute, provide, or transfer any restricted record information or portion of such information

accessed except as authorized by the Department and as set forth in the DPPA and Missouri law.

5. If Requester resells or discloses personal information covered by the DPPA, Requester must ensure that all recipients of the requested

records are authorized under the DPPA and the recipients understand their responsibilities under DPPA. Requester must keep, for a

period of five years, records identifying each person or entity that receives such information and the permitted purpose for which the information

is to be used, and must make such records available to the Department upon request.

6. Requester understands that Section 302.183.2, RSMo, prohibits the sale of data derived from a person’s driver’s license application for

commercial purposes, which includes purposes motivated primarily by financial gain such as, but not limited to,

surveys,

marketing

solicitations, without the express consent of the person to whom such information pertains. Requester shall not sell personal information for

commercial purposes without such consent.

7. The Department reserves the right to audit Requester’s compliance with DPPA. Any such audit shall be performed at reasonable times and

in a reasonable manner as determined by the Department.

8. Requester shall not disclose its Department assigned security access code to anyone other than a Department representative or an

authorized individual who is in the direct employ of Requester.

9. Requester understands that false or misleading statements herein are cause for denial or termination of any access request. Requester

authorizes the Director of Revenue, or the Director’s designee, to investigate any matter or statement contained in this request.

10 Requester understands that according to provisions of the Missouri Revised Statutes and the DPPA, any person holding a security access

code who directly or indirectly obtains information from the Department using false representations or distributes restricted or

confidential information to any person or uses the information for a reason not authorized or specified in this request is liable, subject to penalty,

and may be denied further access.

11. Requester understands that if this request is approved, authorization for DPPA access shall be for a term of one (1) year, commencing

the day and year the security access code is activated, unless otherwise terminated at the sole discretion of the Department. Requester

further understands that this authorization may be renewed for successive one (1) year term(s) upon further request and upon

approval by the Department.

12. Requester understands and agrees that the Department shall not be liable for any damages, including but not limited to actual, direct,

incidental or consequential damages, arising out of or in any way connected with Requester’s access or use of motor vehicle or driver

license record information and that Requester shall indemnify and hold harmless the Department from any claim, loss, cost or

expense, including attorney fees, in relation thereto.

Requester certifies under penalty of perjury that: 1) Requester understands and agrees with each and every statement set forth in this request; 2) all

information provided in this request is true and correct; and 3) the willful and unauthorized access, use or disclosure of information obtained from any

Department record may result in award of damages under Title 18 U.S.C. Section 2724, and imposition of penalties as otherwise provided by law.

Pursuant to Section 571.500, RSMo, requestor shall not use the information received from this request to construct, enable by providing or sharing

records to, maintain, participate in, or develop, or cooperate or enable the federal government in developing, a database or record of the number

or type of firearms, ammunition, or firearms accessories that an individual possesses.

SIGNATURE(S) OF INDIVIDUAL, PARTNERS (ALL REQUIRED), AUTHORIZED MEMBER OR CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

PRINTED NAME(S)

TITLE OF CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

NOTARY INFORMATION

STATE

NOTARY PUBLIC EMBOSSER OR

COUNTY (OR CITY OF ST. LOUIS)

BLACK RUBBER STAMP SEAL