(1) The nongovernmental entity's business/organization name.

(2) The nongovernmental entity's telephone number.

(3) The business and the mailing address of the nongovernmental entity.

(4) The name, addresses and telephone numbers of the branch locations of the nongovernmental entity that will be receiving information from the department;s records.

(5) Any existing requester code(s) issued by the department and used for the nongovernmental entity's business.

(6) Whether the nongovernmental entity will purchase departmental information through a departmental preapproved requester.

(7) Where the nongovernmental entity wants purchased information mailed.

(8) If the nongovernmental entity is required to be licensed by the State of California or if the applicant is a member of the California State Bar list the business license number, the agency issuing the license, the type of license, and the date the license expires. Also, if applicable, list the federal employer identification number, the corporation number, and the state that issued the number.

(9) A description of the business or organization.

(10) The purpose(s) for requesting information.

(11) The medium of inquiry and delivery the nongovernmental entity requests.

(12) Whether the nongovernmental entity will request information from the registration file; the driver's license file; the financial responsibility file; the occupational licensing file; or any combination thereof; and, whether the nongovernmental entity will request mailing address and/or residence address information.

(13) If residence address information will be requested, the specific reasons such information will be requested, and the regulation, federal or state statute, identified by code name and section number, or rule of court that requires the department to release the residence address information.

(14) If mailing address information will be requested, the specific reasons such information will be requested.

(15) Whether or not the nongovernmental entity will resell information to another preapproved requester.

(16) A description of the nongovernmental entity's automated system design to be used for on-line access and record reproduction when the application is for on-line access.

(17) If the applicant is requesting access to residence address or mailing address information, a copy of the procedures established to protect the confidentiality of the information received from the department as required by Vehicle Code section 1808.47. The security procedures shall address at least the extent to which access to the requester code, personal identification number, and information received from department records is restricted.

(18) The name and title of the person signing the agreement described in section 350.18 who is responsible for compliance with the statutes and regulations pertaining to the access and use of information from department records, and a description of the person's position within the nongovernmental entity.

(19) The name, title and telephone number of the person to be contacted by the department to resolve problems.

(20) A sworn statement signed and dated by the person described in subdivision (18) as to the truth of the contents of the application; the penalties for false representation and misuse of information; and, the city, county and state where the document is executed.