# EMPLOYMENT AFFIDAVIT OF INTENDED USE INFORMATION SALES UNIT

| **Field** | **Value** |
| --- | --- |
| Business Type(check one): | Individual / Partnership / Corporation / 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。Check here，如果地址是相同的。 |  |
| 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(MM/DD/YYYY) | Driver LicenseSTATE | Day-Time Phone Number |
| --- | --- | --- | --- | --- |
| 1. |  |  |  |  |
| 2. |  |  |  |  |
| 3. |  |  |  |  |

**Please initial each statement below and submit 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 of Person Administering Oath |  |  |
| E | Sign in Presence of Notary |  |  |
| A L |  |  |  |

Signature

Date

---

## INSTRUCTIONS FOR COMPLETING THE AFFIDAVIT OF INTENDED USE

1. The affidavit must be completed and signed by a member of your agency or firm who has the
authority to certify the agency or firm’s compliance.

2. Please complete each line on the form in its entirety to avoid delays in processing your affidavit.
If requested information does not apply to your business insert **n/a** (not-applicable) on that line.

3. The person responsible for completing the affidavit must initial each of the nine (9) declaration
statements, then sign and date the form in the presence of a Notary.

4. This affidavit must be returned to your information provider.

5. You are required to complete, notarize and file a new Affidavit of Intended Use whenever information
about your company changes. (name, address, ownership, telephone, website, etc.)

6. If you need assistance in completing this affidavit, please contact your information provider.