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A Public Service Agency <br /> INFORMATION SERVICES PROGRAM <br /> GOVERNMENT REQUESTER ACCOUNT APPLICATION <br /> DMV USONLY <br /> PART I APPLICATION REQUESTER CODE EXPIRATION DATE TECH ID <br /> PLEASE PRINT CLEARLY IN INK OR TYPE <br /> SECTION A. TYPE OF APPLICATION <br /> CHECK ONE(1)BOX ONLY' <br /> ❑ Original — Complete ALL SECTIONS — DMV will assign Requester/Parking/Court Code. <br /> 2 Change(s)to Existing Account Complete Sections A, B and C, and all applicable sections where information is changing.Provide <br /> signature in Part II,Section F. Provide current Requester/Parldng/Court Code(s): DS272 <br /> ❑ Renewal — Complete ALL SECTIONS — Provide current Requester/Parking/Court Code(s): <br /> IMPORTANT: TO AVOID PROCESSING DELAYS,PLEASE READ ALL INSTRUCTIONS PRIOR TO COMPLETING FORM. <br /> SECTION B. AGENCY INFORMATION <br /> 1.NAME OF AGENCY 2.DIVISION/PROGRAM THAT WILL REQUEST DEPARTMENT INFORMATION <br /> Everett Police Department Records Unit <br /> 3_AGENCY WEBSITE ADDRESS OR INDICATE"NONE' 4.FAX NUMBER <br /> www.everettwa.gov 425-257-6505 <br /> 5.NAME AND TmE OF THE PERSON FOR DMV CONTACT 6.TELEPHONE 2 E-MAIL ADDRESS <br /> Sandra Albertson, Records Manager ( 425 ) 257-7454 salbertson@everettwa.gov <br /> 8.STREET ADDRESS(PHYSICAL LOCATION) STREET CITY COUNTY STATE ZIP <br /> 3002 Wetmore Ave Everett Snohomish WA 98201 <br /> 9.MAILING ADDRESS OR INDICATE-SAME" 10.RECORD STORAGE PHYSICAL ADDRESS <br /> SAME 3002 Wetmore Ave, Everett,WA 98201 <br /> SECTION C. TYPE OF AGENCY <br /> 3 CHECK APPROPRIATE BOX FOR THE TYPE OF GOVERNMENT AGENCY(CHECK ONLY ONE): <br /> ❑ Federal ❑ State ❑✓ City ❑ County ❑ Special District ❑ Other: <br /> DESCRIBE <br /> 2. IS THIS ACCOUNT BEING ESTABLISHED BY A GOVERNMENT ENTITY EXCLUSIVELY FOR USE BY ONE OF THE FOLLOWING? <br /> 0 Yes,check appropriate box. ❑✓ No,go to Section D. <br /> CALIFORNIA APPLICANTS <br /> ❑"Peace Officers"as described in California.Penal Code§830.1 through 830.5. Identify Section#: <br /> ❑City Attorney prosecuting misdemeanor actions under Government Code Section 41803.5. <br /> ANY STATE OR FEDERAL APPLICANT <br /> ❑Attorney General ❑ District Attorney ❑ Public Defender ❑ Public Defender's Investigator <br /> ❑✓ Government employees having statutory authority to carry firearms AND execute warrants AND make arrests. Identify Statutory <br /> Authority;Code and Section#: RCW 10.31.100,RCW 9.41.060,RCW 10.93.070 <br /> SECTION D. PURPOSE OF ACCOUNT Check one purpose only (Continued on Page 2) <br /> 1. ❑ EPN(Employer Pull Notice)—Check this box if you are enrolling employees in the EPN program. For more information about the <br /> EPN program and to obtain enrollment forms,go to www.dmv.ca.gov and"Search"for EPN General Information. <br /> 2. ❑ UPDATE AND INQUIRY—If yourAgency is applying for authorization to update DMV records(i.e.,courts,parking/toll,revenue recovery, <br /> etc.),check this box. Explain the purpose of updating DMV records(space provided below): <br /> a.❑ VehicleNessel Registration(VR) DMV USE ONLY <br /> Purpose Approved? <br /> PURPOSE OF UPDATE: <br /> ❑Yes 111 No <br /> b.❑ Driver License/Identification Card(DL) DMV USE ONLY <br /> PURPOSE OF UPDATE Purpose Approved? <br /> ❑Yes ❑ No <br /> • <br /> INF 1130(REV.10/2013)WWW 1 6f44 <br />