GREEN MOUNTAIN SUPPORT SERVICES

ENSURING NEIGHBORS WITH DISABILTIES ARE AT HOME IN THEIRlCOMMUNITY.

You have accepted a job or live in a home that requires you to act as an advocate on behalf of vulnerable adults and children. We request background information and records from Vermont Criminal Information Center {VCIC also other states), Adult Protective Services {APS), Department of Children and Families {DCF formerly SRS), Department of Motor Vehicles {DMV) and Office of the Inspector General {OIG) as part of the hiring process and annually. Are any of these a concern for you?

Adult Protective Services, HC 2 South, 280 State Drive, Waterbury, VT 05671-2060

Child Abuse Registry Unit, 280 State Drive, HC 1 North Bldg. B, VT 05671-2401

This form is for use with the ON-LINE registry checking system ONLY

**** This consent form must be filled out completely and signed by the current employee, prospective

employee, contractor or volunteer and kept on file at the requesting organization. The Agency of

Human Services reserves the right to audit these consent forms at any time.

Current or Prospective Employee, Contractor, or Volunteer Information

I hereby authorize release of any information of reports of abuse, neglect or exploitation substantiated against me and contained in the Vermont Adult Abuse Registry and/or the Vermont Child Protection Registryto: Green Mt Support Services.

Last Modified: 06/05/2018 8:10 AM

Agency of Transportation dmv.vermont.gov

120 State St Montpelier, Vermont 05603-0001 802.828.2000

All applicable sections of this form (front and back) must be completed to obtain the

requested information. Do not mail cash! Make check or money order payable (in U.S. funds) to: Vermont Department of Motor Vehicles.

All requests must include proof of identification (i.e., copy of your state issued ID For a driver record other than your own please also include documentation proving you are authorized to obtain the requested information. All requests not including required documentation will be returned.

Signature required on back of form.

Mail to (if different than above):

Listing of 1 - 4 current or expired registrations – $8.00 Listing of 1 - 4 current or expired operator’s license – $8.00 Certified copy of current or original registration application – $8.00 Certified copy of expired operator’s license application – $8.00 Certified copy individual accident report – $12.00 Certified copy police accident report – $18.00 Insurance information of accident – $8.00 Statistics and research – $42.00 per hour List of registered dealers, transporters, periodic inspection stations, rental vehicle companies, fuel dealers and distributors (including gallons sold or delivered - $8.00 per page

Periodic inspection sticker record – $8.00 Certified copy of suspension notice – $8.00 Certified copy of reinstatement notice – $8.00 Certified copy of title – $6.00 Certified copy of vehicle title search, title info, lien info. – $22.00 Certified copy of vessel, snowmobile, or ATV title search – $13.00 Certified copy of 3-year operating record (Vermont only) – $14.00 Certified copy of complete operating record (Vermont only) – $20.00

Other – Provide detailed explanation on reverse side. All other forms of information requested provided will be at a minimum of $8.00 per page

concerning(complete as much information as possible):

Specific information requested:

Detailed explanation of intended use(attach additional sheet if necessary):

The information requested may be disclosed if authorized by the Driver Privacy Protection Act. Information being requested is (initialappropriate category below*1):

1. acting on behalf of a government agency in carrying out its functions. (18 U.S.C. §2721(b1

For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person

2. For use in connection with matters of motor vehicles 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. (18 U.S.C. §2721(b2

3. For use in the formal course of business by a legitimate business or its agents, employees, or contractors to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors. (18 U.S.C. §2721(b3A If information provided does not match DMV records, correct information will not be provided. DMV will only disclose that information does not match.

4. For use in connection with any proceeding in any court or government 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 any court. (18 U.S.C. §2721(b4

5. 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, antifraud activities, rating, or underwriting. (18 U.S.C. §2721(b6

6. For use by an employer, of its agent or insurer, to obtain or verify information relating to a holder of a commercial driver's license which is required under the Commercial Motor Vehicle Safety Act of 1996 [Title XII of Public Law 99-570]. (18 U.S.C. §2721(b9

7. Unrestricted or specified use with written consent of the person who is the subject of the information. This includes information regarding oneself ("Authorization of Release" below must be completed in full (18 U.S.C. §2721(b13

8. For any use specifically authorized by law that is related to the operation of a motor vehicle or public safety. (18 U.S.C. §2721(b14

I hereby, with my signature, authorize (name of person or business you are authorizing):

To perform a one-timesearch of the Vermont Department of Motor Vehicles files pertaining to me and any resulting reports. Or

A one-timeauthorization to transact business pertaining to me within the Vermont Department of Motor Vehicles.

In requesting and using this information I acknowledge that this disclosure and any re-disclosure is subject to the Driver Privacy

Protection Act (18 U.S.C. §2723 This is signed and the request is made subject to penalties of 18 U.S.C §2723 and V.S.A. §202.

Driver’s license number of requestor:

Upon receipt of this request by the Vermont Department of Motor Vehicles, it will be reviewed by appropriate personnel to determine whether this request conforms to DPPA protocol and requirements. Failure to meet these qualifications or to provide adequateinformation to make a determination will result in the denial of your request.

DEPARTMENTUSEONLY–DONOTWRITEBEYONDTHIS

This request is hereby denied as the record(s) is/are exempt from inspection and copying for the following reason: They are records which, by law, are designated confidential or by a similar term. They are records which, by law, may only be disclosed to specifically designated persons.

You have the right to appeal this denial to the Commissioner of Motor Vehicles(must be submitted in writing

Vermont Department of Motor Vehicles