Fillable Printable Form MV-372R - Application for Private Service Bureau License Renewal - New York

Form MV-372R - Application for Private Service Bureau License Renewal - New York

APPLICATION FOR PRIVATE SERVICE BUREAU LICENSE RENEWAL

Name of Private Service Bureau PSB License No. Date of Application (Month/Day/Year)

/ /

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

Type of Business (check one of the following):

o Sole Proprietor o Partnership o Corporation o Association

INSTRUCTIONS: u Print or type the information requested in this application.

u Include a photocopy of the owner’s or employee’s valid New York State driver license or non-driver ID card.

u Include a photocopy of the Workers’ Compensation exemption form, or proof of disability insurance.

u Include a photocopy of the receipt that you give to your customers.

5. Do you have employees who are not volunteers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ ¨

If YES, are these employees paid? ¨ YES ¨ NO

1. Has there been a change in the name of the business since the current license was issued?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

¨ ¨

If YES, provide the former name of the business and the reason for the business name change.

2. If your business is a partnership, has any partner changed since the current license was issued?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

¨ ¨

If YES, provide the names of the previous and current partners and reason(s) for each change.

3. Have you changed your business address or the address of any branch office since your current license was issued? . . . . . . . . . . . . .

¨ ¨

If YES, provide the previous address(es) and the reason(s) for the change.

4. Have you discontinued your business or closed any branch office since your current license was issued? . . . . . . . . . . . . . . . . . . . . . .

¨ ¨

If YES, provide an explanation for discontinuing your business or closing any branch office of your business.

If YES, was the license certificate surrendered to the Department of Motor Vehicles?

¨ YES ¨ NO

MV-372R (10/15)

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Yes No

ANSWER QUESTIONS #1-#7 below.

Your Private Service Bureau license, issued by the Department of Motor Vehicles, expires on June 30. In order to renew your license, you

must answer all of the questions on this application and return the completed application with a check or money order payable to the

Commissioner of Motor Vehicles in the amount of $50.00 (the two-year, NON-REFUNDABLE, renewal fee).

Telephone No.

( )

Fax No.

( )

E-mail Address

o Other, specify

If you have employees, attach a photocopy of your valid NYS driver license or non-driver ID card and attach a photocopy of

the valid NYS driver license or non-driver ID card for every employee, along with a copy of your CURRENT disability

insurance policy.

If you do not have employees, attach a photocopy of your valid NYS driver license or non-driver ID card and a CURRENT,

completed copy of the Workers’ Compensation exemption form. You can obtain this form at your local Workers’ Compensation

office or online at www.wcb.ny.gov. This form states that you have NO employees. You do not have to have employees in New

York State in order to conduct business in New York State. The Workers’ Compensation exemption form must be updated every

time you renew your PSB license.

6. At which DMV office or processing center is your paperwork processed? _______________________________________________

Service Provided Fee Charged

REQUIREMENTS

As a condition for receiving a renewed Private Service Bureau license, the undersigned agree to all of the following requirements:

CERTIFICATION

The Undersigned certify that they have read and understood the foregoing application, and possess sufficient knowledge of the contents hereof to

state that all information provided in this application is true and accurate. Each owner, partner, manager, business officer and major stockholder

(20% or more) of the Private Service Bureau must sign in the space provided below

7. What services do you offer to your customers, and what fees do you charge for these services?

MV-372R (10/15)

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To maintain adequate records, as required by the New York State Vehicle and Traffic Law and Commissioner’s Rules and Regulations, and to

permit the inspection of such records at reasonable times by an authorized representative of the Department. The Department of Motor Vehicles

considers “reasonable times” to be 9:00 A.M. to 5:00 P.M., Monday through Friday.

Not to employ or use employees, runners or agents (paid or unpaid) who have been convicted of a felony or misdemeanor unless each

employee, runner or agent is approved by the Commissioner of Motor Vehicles.

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.

To comply with all provisions of the New York State Vehicle and Traffic Law, Commissioner’s Rules and Regulations, and Department

directives relating to a Private Service Bureau.

Please return this completed, signed form with all required documentation and your non-refundable, two-year, $50.00 renewal fee to:

NYS Department of Motor Vehicles

ATTN: Cassie Campbell

Registration Services

6 Empire State Plaza, Room 322

Albany, NY 12228

New York State Vehicle and Traffic Law Section 394(5) authorizes the Department to suspend or revoke a Private Service Bureau

license or to refuse to renew a license in the event that the licensee makes a materially false statement or conceals a material fact in

connection with his or her application for a license or renewal of a license.

If you have any questions concerning this renewal application, you may contact our office at (518) 473-6586 or (518) 473-9947.

www.dmv.ny.gov

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