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Complete form below, sign and email as an attachment to: support@usabackground.com or you can fax to 305-402-3181
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(Complete one per company/organization)

To obtain Record(s), you must declare your intended use of the information therein. If you are acting as an agent or employee, you must identify the company or entity on whose behalf you are requesting the records.


□ (01) For use by any government agency, including any court or law enforcement agency, in 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.

□ (02) 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 removal of non-owner records from the original owner records of motor vehicle manufacturers.

□ (03) For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only:

(A) to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; and (B) 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; provided, however the legitimate business may only be an insured state-chartered or federally chartered credit union, an insured state or national bank, an insured state or federal savings and loan association, or an insured saving only.

□ (04) 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 the 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.

□ (06) 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, anti-fraud activities, rating or underwriting.

□ (07) For use in providing notice to the owners of towed or impounded vehicles.

□ (08) For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.

□ (09) 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 of 1986 (49 U.S.C. App 2710 et seq).

□ (10) For use in connection with the operation of private toll transportation facilities.

□ (13) For use by any requestor, if the requestor demonstrates it has obtained the written consent of the individual to whom the information pertains.

□ (14) For any other use specifically authorized under the laws of the State that holds the records, if such use is related to the operation of a motor vehicle or public safety. Specify: __________________________________

Under penalty of perjury, I attest that I shall not obtain, resell, transfer, or use the information in any manner prohibited by law. I understand that motor vehicle or driver records or other information obtained, resold, or transferred for purposes prohibited by law may subject me to civil penalties under federal and state law.

Company Name: _______________________________________________________________

Corporate Officer Signature: ______________________________ Title: __________________

Printed Name: _________________________________________ Date: __________________

Phone: (______) _______________ ext. _______