Data Records Contract Application
Use this form to apply for a direct interface (web or SFT) with Department of Licensing (DOL) for data. We are
committed to safeguarding Protected Personal Information and only release it as allowed by Washington State
and federal laws. We strive to provide data on the timing you request but cannot guarantee when the le will be
delivered. For public agencies, this application meets the requirements of RCW 39.34.240.
If your use of data is permissible under federal or state law, you will be contacted to schedule an interview to
discuss the application. If your application is approved, you will be responsible for contract fees. This may include
set up and data charges. You will be required to sign DOL’s contract to receive data. Third-party data security and
permissible use audits are done at regular intervals to verify you are compliant with your contract and Washington
State law. You are responsible for all costs associated with the audits.
For more information go to dol.wa.gov/
about/data-services-requests.html and dol.wa.gov/privacy/how-we-use-your-info.html
.
Email this completed form to: [email protected].
Application must be lled out completely, including all attachments. Incomplete applications will be delayed or rejected.
1 – Applicant information
Business name
Applicant type EIN/ UBI number Business website
Doing business as (DBA) name, if applicable
Physical address (Street address, City, State, ZIP code)
Mailing address if dierent (Address or PO Box, City, State, ZIP code)
Contact name Email 10-digit phone number
List all subsidiaries and parent companies
Former business name, if applicable
Business description – Provide a detailed explanation of your primary business activities and how it relates to the data requested
Answer the following
1. Are you applying for: a new contract an update to a current contract
2. If you are a public agency, are you inside the State Government Network (SGN)?............ Yes No
2 – Data requested
Type of data requested
Driver Vehicle Vessel Manufactured home
How often do you want the data? If “Other,” describe
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Choose one
WA businessNon-WA business (attach license)GovernmentPrivate citizenNon-profit organizationOther
Choose one
One-timeDailyWeeklyMonthlyYearlyOther (enter short description)
Denition
“Protected Personal Information” means collectively Personal Information and Identity Information, as
dened by RCWs 46.04.209, 19.255.005 and 42.56.590, authorized for disclosure by the federal Driver Privacy
Protection Act and state law.
“Subrecipient” means any entity outside your immediate organization that receives or has access to
protected personal information including, but not limited to subsidiaries, subcontractors, requesters or agents.
“Bona Fide Research Organization” means an entity, such as a university, that conducts non-commercial
research using established scientic methods. There must be an intention to publish the research ndings for
wider scientic and public benet, without restrictions or delay.
“Oshoring” means the electronic or hardcopy transmission, accessing, viewing, capturing images, storage or
processing of protected personal information outside the United States.
Answer the following
1. Are you requesting Protected Personal Information?................................... Yes No
2. Have you read the contract template? .............................................. Yes No
3. Will you redisclose or sell Protected Personal Information to any Subrecipients?............. Yes No
4. Are you a consumer reporting agency? ............................................ Yes No
3 –Driver data records
Data type
Abstract driver record (ADR) (select all that apply)
Employment Insurance Transit Volunteer organization Transportation network companies Monitoring
Governmental Other, list:
NOTE: If requesting ADRs, you must set up a banking account for automatic withdrawals.
Aggregate data – List data elds needed (i.e. name, address, height, weight, etc.)
Purpose for the data
Research Governmental Statistical reports Other
If requesting Protected Personal Information, what law allows DOL to share this information with you?
Explain, including citations to applicable law.
If “Research” was selected, answer the following:
1. What is the public benet?
2. Have you submitted your research to an Institutional Review Board? ..................... Yes No
If “Yes,” what is the status?
NOTE: You may be required to provide us a copy of the results when the research is completed.
3. Will you redisclose or publish the data, or contact individuals about the data? ............. Yes No
4. Are you a Bona Fide Research Organization? ....................................... Yes No
If “Statistical reports” was selected, answer the following:
1. Will you redisclose or publish the data, or contact individuals about the data? .............. Yes No
2. Who will you provide the reports to and for what purpose?
Detailed description of why you need the data and how you will use the data
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4 – Vehicle, Vessel, Manufactured home data records
Purpose for the data (check all that apply)
Parking (gov’t only) Tolling Manufacturer recalls Governmental Towing
Photo enhancement Insurance Research Statistical reports
Other
If requesting Protected Personal Information, what law allows DOL to share this information with you?
Explain, including citation to applicable law.
If “Research” was selected, answer the following:
1. What is the public benet?
2. Have you submitted your research to an Institutional Review Board? ..................... Yes No
If “Yes,” what is the status?
NOTE: You may be required to provide us a copy of the results when the research is completed.
3. Will you redisclose or publish the data, or contact individuals about the data? ............. Yes No
4. Are you a Bona Fide Research Organization? ....................................... Yes No
If “Statistical reports” was selected, answer the following:
1. Will you redisclose or publish the data or contact individuals about the data?............... Yes No
2. Who will you provide the reports to and for what purpose?
Detailed explanation of why you need the data and how you will use the data.
5 – Data security and permissible use requirements
Requirements – Answer the following
1. Have you read DOL’s Privacy and Security Requirements? ........................... Yes No
If “Yes,” do you meet the Privacy and Security Requirements? ......................... Yes No
2. Do you and your IT organization understand by receiving Protected Personal Information
you are subject to data Privacy and Security Requirements and are required to pay for
any audit costs? ............................................................. Yes No
3. Do you and your IT organization understand the audit documentation and evidence of
audit procedures must be submitted to DOL? ...................................... Yes No
Answer the following
1. Where will you store the data? Specically include type of servers, name, city and state of secure
data center. Do not include any information on vulnerabilities to your data security environment on this
application. We will discuss in a teleconference during the review of your application.
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2. Will you use a cloud service provider? ............................................ Yes No
If “Yes,” who is the supplier?
Where are the servers located?
3. Do you have a back-up system for the data? ....................................... Yes No
If “Yes,” where are they located?
4. Have you had a recent data security audit? ........................................ Yes No
If “Yes,” when? What type of audit?
Were any deciencies found?................................................... Yes No
If “Yes,” have they been corrected? .............................................. Yes No
5. Do you have a data ow chart you can make available upon request? ................... Yes No
6. Do you have a privacy policy? .................................................. Yes No
If “Yes,” attach.
7. What cyber security industry standard do you use?
8. Are you or any of your Subrecipients Oshoring, as dened, Protected Personal Information? Yes No
If “Yes,” where?
9. Will you comingle our data with information from other sources? ....................... Yes No
If “Yes”, describe:
10. Will you link the records to any other records? ...................................... Yes No
If “Yes,” describe:
11. Describe in detail your plan to prevent unauthorized access or redisclosure.
12. Do you have a data disposal policy? .............................................. Yes No
If “Yes,” attach.
13. How long will you keep this data?
14. What is your plan for disposing of the data?
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X
6 – Subrecipient redisclosure information
Laws restrict redisclosure of Protected Personal Information obtained from data records. An authorized recipient
may only redisclose information for a permissible use.
Answer the following – Provide specic and detailed explanations
1. What process do you use to screen Subrecipients?
2. How will you monitor Subrecipients to make sure they use Protected Personal Information appropriately?
3. How will you make sure Subrecipients meet DOL’s Privacy and Security Requirements?
4. How will you transfer the data to Subrecipients? (Example: data held in a database that employer accesses,
send an abstract driving record to the employer and retain the data, etc.)
5. Do you approve Subrecipients Oshoring of Protected Personal Information? .............. Yes No
6. Do you have data sharing agreements in place with Subrecipients? ...................... Yes No
If “Yes,” provide a copy of the template.
Attachments
The following documents are attached:
Business license (non-Washington businesses)
Privacy policies
Data disposal policy
Subrecipients data sharing agreement template
7 –Certication
Contract manager name Title Email 10-digit phone number
Compliance manager name Title Email 10-digit phone number
Technical contact name Title Email 10-digit phone number
Contract signer, if dierent than contract mgr. Title Email 10-digit phone number
Knowingly making a false statement or concealing a material fact required in this request or making false
representation to obtain any Protected Personal Information from an individual’s data record is subject to
federal criminal nes and civil penalties under RCW 46.22.010.
By signing or typing my name, I declare under penalty of perjury under the law of Washington that the foregoing is
true and correct.
Date and place (city or county) signed Contract manager or authorized representative signature
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