Fillable Printable Form MV-372 - License Application to Operate Private Service Bureau/Open Branch Office - New York

Form MV-372 - License Application to Operate Private Service Bureau/Open Branch Office - New York

OFFICE USE ONLY

Date

Name

Application No.

Lic. #

Name of Private Service Bureau Federal Employer ID Number* Date of Application (Mo./Day/Yr.)

Mailing Address of Private Service Bureau (Street & No.) City State Zip Code

If you also plan to operate a branch office, provide the branch office address:

Telephone

( )

Fax #

( )

Type of Business (check one of the following):

o Sole Proprietor o Partnership o Corporation o Association

Owners

Partners

Corp. Officers

Managers

Major Stockholders

INSTRUCTIONS:

u Print or type the information in this application.

u Refer to the Private Service Bureau page of the NYS DMV website (http://dmv.ny.gov/more-info/about-private-service-bureau-licenses)

for information about the documents that must accompany this application.

FEE SCHEDULE

Original Application . . . . . . $25.00

Branch Office(per branch). $ 1.50

An additional $25.00 license fee

will be required upon approval

APPLICATION FOR A LICENSE

TO OPERATE A

PRIVATE SERVICE BUREAU OR

OPEN A BRANCH OFFICE

List names, addresses and social security numbers of all owners, partners, corporation officers, stockholders and managers,(continue on additional sheet, if necessary).

A photocopy of the NYS Driver License or Non-Driver ID card for all owners, partners, corporate officers, managers and major stockholders, is required.

Social Security Number* Address

*As required by Section 5 of the NYS Tax Law, the social security number of individuals and the Federal Employer ID Number of businesses regulated by

the Department of Motor Vehicles must be given to the New York State Department of Tax and Finance.

1. Have any of the owners, partners, corporation officers, managers or major stockholders ever operated a Private Service Bureau before?

(If Yes, complete “Explanations” section below by giving dates of operation and reason for discontinuance if not still in operation) . . . . . . . . . .

2. Where is your Private Service Bureau operated from? (for example, office space, residence, etc.) ________________________________

3. Is the Private Service Bureau conducted in conjunction with any other business? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If Yes, what kind of business? _________________________________________________________________________________________

4. Is your Private Service Bureau within 1500 feet from the nearest state or county office where driver licenses or vehicle registrations are issued? . . .

5. Do you share office space or desk room with any other business? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . oo

If Yes, what kind of business? ____________________________________________________________________________

MV-372 (10/15)

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EXPLANATIONS

CHECK ONE

Yes No

ANSWER ALL QUESTIONS IN THE FOLLOWING SECTION:

Signature ç Title

Name

EMPLOYEES/RUNNERS/AGENTS (PAID OR UNPAID)

CONDITIONS

AFFIRMATION

Address NYS Driver License or Non-Driver ID No.*

List all employees/runners/agents (paid or unpaid) working at or associated with the Private Service Bureau.

*Note:

ALL EMPLOYEES/RUNNERS/AGENTS (PAID OR UNPAID) WHO HAVE DIRECT IN-PERSON CONTACT WITH CUSTOMERS AND/OR

DMV, MUST HAVE EITHER A VALID NYS DRIVER LICENSE OR A VALID NYS NON-DRIVER IDENTIFICATION CARD.

As a condition for issuing a Private Service Bureau License, the undersigned agree to all of the following conditions:

A. To maintain adequate records, as required by the New York State Vehicle and Traffic Law and Rules and Regulations, and to permit the inspection of

such records at reasonable times by an authorized representative of DMV. The Department of Motor Vehicles considers “reasonable time” to be

9:00 A.M. to 5:00 P.M., Monday thru Friday.

B. Not to employ or use employees/runners/agents (paid or unpaid) who have been convicted of a felony or misdemeanor unless each employee is

approved by the Commissioner of Motor Vehicles.

C. To comply with all state laws and regulations, and all municipal ordinances and regulations relating to public health and public safety for the business facility.

D. To comply with all provisions of the New York State Vehicle and Traffic Law and Rules and Regulations relating to a Private Service Bureau.

All of the undersigned affirm they have read the entire application, are familiar with all its contents, and all answers, statements and all other matters in it are true.

Each owner, partner, manager, corporation officer and major stockholder (20% or more) of the Private Service Bureau must sign in the space provided below.

To knowingly make a false statement or conceal a material fact in this application is a criminal

offense, and will result in the revocation of your Private Service Bureau License. False statements

are punishable under Section 210.45 of the Penal Code.

Pursuant to Vehicle and Traffic Law - 392, any person knowingly making a false statement in an

application for any document issued by the Department or in any proof or statement in writing in

connection with such an application shall be guilty of a misdemeanor.

Vehicle and Traffic Law - 394(5) authorizes the Department to suspend or revoke a Private Service

Bureau license or refuse to issue a renewal thereof where the licensee has made a material false

statement or concealed a material fact in connection with his or her application for a license or renewal.

MV-372 (10/15)

Signature ç Title

Please return this form with all required

documentation and application fee to:

Private Service Bureau Unit

NYS Department of Motor Vehicles

6 Empire Plaza, Room 322P

Albany NY 12228

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