Information Services Certificate of Agency

PLEASE CHECK THE APPROPRIATE BOX BELOW:

• My business is a vehicle dealership licensed to do business in the state of California.
• My business is a vehicle manufacturer licensed to do business in the state of California.
  
  

PLEASE PRINT THE FOLLOWING INFORMATION REGARDING YOUR BUSINESS:

_______________________________________________________________________________________________________________ (Name) ________________________________________________________________________________________________________________ (Address)                    (Street)                                                             (City)                                         (State)                     (Zip) ________________________________________________________________________________________________________________ (Dealer Manufacturer License Number)                                          (Daytime Telephone Number)

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 Vehicle Code Section 1808.23.

In making this authorization I agree to:

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 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 representation, 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.


PLEASE PRINT THE FOLLOWING INFORMATION REGARDING THE AGENT YOU ARE AUTHORIZING:

_______________________________________________________________________________________________________________ (Name) ________________________________________________________________________________________________________________ (Address)                    (Street)                                                             (City)                                         (State)                     (Zip) ________________________________________________________________________________________________________________ (Driver License Number)                                          (Telephone Number)

I certify, under penalty of perjury, that the forgoing is true and correct.

________________________________________________________________________________________________________________ (Executed at)                                                                                 (City)                                         (County)                     (State) ________________________________________________________________________________________________________________ (Date)                                          (Signature of Dealer or Manufacturer)