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Application For Certification As A Motor Vehicle Inspector VS-120 - New York
| Application For Certification As A Motor Vehicle Inspector Form. This is a New York form and can be used in Department Of Motor Vehicles Statewide . |
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New York State Department of Motor Vehicles FOR OFFICE USE ONLY APPLICATION FOR CERTIFICATION AS A MOTOR VEHICLE INSPECTOR N CIA CIO CIC CIS CIG CID Certificate Number County FOR ORIGINAL APPLICATIONS: Answer ALL questions on Page 1 and Page 2 that CIRCLE ONE: OE ADD apply to you, and SIGN the application on PAGE 2 or it will be returned to you for Note: Check or money order must be attached to completion. You MUST be at least 17 years old and have AT LEAST ONE YEAR OF enter OE or ADD MOTOR VEHICLE REPAIR EXPERIENCE in the last 5 years immediately preceding this Group(s) 1 2 3 application, in the area in which you apply to be certified, or you must provide a copy of A A AA an acceptable school diploma in vocational motor vehicle trades. When your application Y N is approved, DMV will notify you by mail of the date, time and location of the inspector Address Change training class. You MUST present photo ID at the class as proof of identity. If you have difficulty reading or understanding written material, please contact the office identified at TEST RESULTS the bottom of page 2 of this form. Group(s) 1 2 3 N FOR AMENDMENT AND DUPLICATE APPLICATIONS: Answer questions 1-21 and SIGN in #25. REQUIRED FEES Non-refundable application fee ($10) and three-year certification fee ($15). Make check or money order for $25 payable to the Commissioner of Motor Vehicles. You MUST send your check with this application. Starter checks are not accepted. P F N W Y P F N W N P F N W N P F N W Y N 1± 2± 3± 4± Check type of application: ORIGINAL AMENDMENT (No Fee) DUPLICATE (No Fee) Yes No Have you ever applied for or taken a test to become a Certified Motor Vehicle Inspector? Have you ever been a Certified Motor Vehicle Inspector and/or Body Damage Estimator? Yes No If "Yes," please write your Certification No. ___________________________________ Check all certification groups for which you are applying. Group 1 (Allows an individual to conduct safety, diesel emissions, OBDII emissions, and low enhanced emissions inspections of motor vehicles that have a seating capacity under fifteen passengers, and motor vehicles and trailers that have a MGW under 18,001 pounds, except motorcycles and semi-trailers) Group 2 (Allows an individual to conduct safety and diesel emissions inspections of motor vehicles that have a seating capacity over fourteen passengers, motor vehicles and trailers that have a MGW over 18,000 pounds, and semi-trailers, except motorcycles) Group 3 (Allows an individual to conduct safety inspections of motorcycles) Please print or type in the open spaces next to the arrows. LAST NAME FIRST M.I. DATE OF BIRTH SEX Year 5± MAILING ADDRESS (Include Street No., Rural Delivery and/or Box No.) 6± 9± STREET NAME APT. NO. Month Day / HEIGHT Feet / Inches 7± Male Female EYE COLOR 8± 11± CITY OR TOWN STATE ZIP CODE 10± HOME TELEPHONE (Include Area Code) 12± ( ) COUNTY 13± HOME ADDRESS (If Different From Mailing Address) NUMBER AND STREET (Include Street No., Rural Delivery and/or Box No.) 14± APARTMENT NO. CITY STATE ZIP CODE 15± 16± Has your address changed since your last certification was issued? CLIENT IDENTIFICATION NUMBER (From New York State driver license or non-driver ID) NOTE: Failure to provide a valid Client ID number will prevent issuance of a Certified Inspector card. Yes No 17± Check this box if you do not currently have a New York State driver license or non-driver ID. A form (ID-5 VSCI ) will be mailed to you with instructions on how to obtain a Client ID number. PLEASE CONTINUE, AND SIGN ON PAGE 2. VS-120 (1/11) *VS-120* PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com PRESENT EMPLOYER FACILITY NUMBER 18± 21 ± 22 ± BUSINESS ADDRESS (NUMBER AND STREET) 19± CITY 20± BUSINESS TELEPHONE NUMBER ( ) STATE ZIP CODE FOR ORIGINAL APPLICATIONS ONLY Have you ever been convicted of any felony, misdemeanor or improper motor vehicle inspection? Yes No If "YES," give details below: (Applicants will not necessarily be rejected because of a conviction record. Such applications will be reviewed on an individual basis.) Date of Violation Nature of Violation Date of Conviction Disposition & Fine Court Location 23 ± FOR ORIGINAL APPLICATIONS ONLY By month and year, list the dates of all your motor vehicle repair experience. You must have at least one year of motor vehicle repair experience in the last five years immediately preceding the date of this application. Attach additional sheets if necessary. Dates (From - To) Employer's Name and Address Describe Type of Repairs Performed (be specific) 24 ± FOR ORIGINAL APPLICATIONS ONLY List any trade school, vocational school, or other motor vehicle repair courses taken. Only approved schools are acceptable. You must provide a COPY of your diploma if you have less than one year of work experience. Dates Attended School Name and Address Type of Course Degree, Diploma or Certificate Section 304(a) of the Vehicle & Traffic Law provides for the certification of motor vehicle inspection personnel. A Certified Inspector agrees to comply with the rules and regulations promulgated by the Commissioner of Motor Vehicles. Failure to comply with these rules and regulations may result in the revocation of this certification. FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW. 25 ± NAME (PLEASE PRINT) __________________________________________________________ Date _________________ (Sign Name in Full - DO NOT PRINT - No Nicknames) SIGNATURE __________________________________________ N SEND APPLICATION AND CHECK TO: BUREAU OF CONSUMER AND FACILITY SERVICES Attn: Certification Unit PO Box 2700 Albany NY 12220-0700 Telephone (518) 474-7998 NOTE: Notify this office of any change in your address. VS-120 (1/11) www.dmv.ny.gov PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com
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