Fillable Printable Form MV-521.1 - Personal History - New York

Form MV-521.1 - Personal History - New York

PERSONAL HISTORY

Please

Check

One:

o DRIVING SCHOOL

Department of Motor Vehicles, Bureau of Driver Training Programs, 6 Empire State Plaza, Room 412, Albany NY 12228.

PRIVATE SERVICE BUREAU UNIT

Private Service Bureau Unit, Registration Services, 6 Empire State Plaza, Room 322P, Albany , NY 12228

Instructions: Please print in blue or black ink. Each owner, partner, corporate officer, manager, agent, employee (other than instructor), and

major stockholder (20% or more) listed on any application for the original license or for a branch license, or who has become newly associated

with the business in any of its capacities, MUST fill out a Personal History form. Return this form to:

Last Name First M.I. Title Social Security Number

Home Phone Number

( )

License Expiration Date (Month/Day/Year)

/ /

Date of Birth (Month/Day/Year)

/ / o Male o Female

Business Phone Number

( )

Home Mailing Address (Street & Number) City State Zip Code Apt. #

Driver License I.D. Number

Place of Birth

Name of Business

Address of Business (Street & Number) City State Zip Code

Note: Section 5 of the NYS Tax Law requires the Department of Motor Vehicles to provide Social Security numbers to the NYS Department

of Taxation and Finance upon request.

LIST EMPLOYMENT EXPERIENCE FOR LAST 5 YEARS. List the most recent first. (Attach additional sheets, if necessary.)

ANSWER ALL QUESTIONS

CHECK ONE

For every question answered “yes”, you must provide a complete explanation on page 2 of this form.

Yes No

Name and Address of Business

Job Description/Title Dates Employed (month/year)

From To

Dates Employed (month/year)

From To

Dates Employed (month/year)

From To

Dates Employed (month/year)

From To

Name and Address of Business

Job Description/Title

Name and Address of Business

Job Description/Title

Name and Address of Business

Job Description/Title

Reason for Leaving

Dates Employed (month/year)

From To

Name and Address of Business

Job Description/Title

Reason for Leaving

1. Have you ever been known by any name other than the one shown on this personal history form?. . . . . . . . . . . . . . . . . . . . . . . o o

2. Have you ever been convicted of a felony, or of any crime involving violence, dishonesty, deceit, indecency, degeneracy or

moral turpitude? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

3. Have you ever been convicted of perjury or of making any false statements relating to any part of the New York State

Vehicle and Traffic Law? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

4. Are you now involved with any charges or court proceedings relating to the matter stated in question 3? . . . . . . . . . . . . . . . . . o o

5. Have you ever been convicted of any traffic violations (not parking violations)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

6. Has your driver license ever been denied, cancelled, suspended or revoked in New York or any state? . . . . . . . . . . . . . . . . . . . o o

7. a. Have you been affiliated with, or employed by, any other driving school(s) or Private Service Bureaus? . . . . . . . . . . . . . . . . . . o o

b. If “yes”, list the name(s) of the schools or Private Service Bureaus:

Continue on Page 2

PAGE 1 OF 2

MV-521.1 (9/15)

To knowingly make a false statement or to conceal a material fact on this form is a criminal offense, and may result in

the revocation of your Driving School License and/or Private Service Bureau License and/or Instructor Certificate.

I affirm under penalty of perjury that I have read this form and know the contents, and that all answers and statements are true. False

statements are punishable under Section 210.45 of the Penal Code.

Name (Please print) ç _____________________________________________________________

Applicant’s Signature ç ____________________________________________________________ Date ______________________________

Sworn to before me this ____________ Day of ________________________________ in the Year of _________.

Notary Public Number and Signature

If there is any change regarding any information on this form, it must be reported in writing within ten days to the

Driving school at:

Department of Motor Vehicles, Bureau of Driver Training Programs, 6 Empire State Plaza, Room 412, Albany NY 12228.

Private Service Bureau Unit at:

Private Service Bureau Unit, Registration Services, 6 Empire State Plaza, Room 322P, Albany, NY 12228.

CHECK ONE

Yes No

8. Have you ever had a Private Service Bureau License, Driving School License, or Instructor’s Certificate denied, cancelled,

suspended or revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

o o

9. Within the past 12 months, have you been paid for giving driver training instruction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

10. Within the past 12 months, have you been an instructor for a Point Insurance Reduction Program? . . . . . . . . . . . . . . . . . . . . . . o o

11. Within the past 12 months, have you been employed by a Private Service Bureau? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

12. Have you ever been an officer, director, employee, stockholder, partner or owner in a corporation, or a partner in a business,

which has had a driving school license, or Private Service Bureau license revoked or suspended by the Department of Motor

Vehicles? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

Use this space to explain any questions answered “Yes”. Please include the number of the question you are explaining. Attach additional pages,

if necessary and print your name on each attached page.

MV-521.1 (9/15)

ATTACH

PHOTO

Photograph must have been

taken within past 30 days and

should be 1 7/8” wide by 2”

long, and must be a true

likeness showing only the

shoulders, neck and uncovered

head.

THIS FORM SHOULD BE SENT TO THE DEPARTMENT OF MOTOR VEHICLES

WITH THE APPLICATION PACKAGE.

PAGE 2 OF 2www.dmv.ny.gov

Social Security #: ______________________________

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