Fillable Printable Form VS-114I - MV-50 Retail/MV-50W Wholesale - New York

Form VS-114I - MV-50 Retail/MV-50W Wholesale - New York

VS-114I (9/15)

MV-50 RETAIL/MV-50W WHOLESALE ORDER FORM

www.dmv.ny.gov

FACILITY INFORMATION

INSTRUCTIONS

IMPORTANT: You must return a completely used book

before we can give you a new book.

To order a new supply of MV-50s or MV-50Ws:

1. sign and date this order and enclose a check or money order payable to COMMISSIONER

OF MOTOR VEHICLES. DO NOT SEND CASH.

2. write your facility number on your check or money order.

3. optional: If you would like your order returned by express delivery service, add $10.00 to the

total cost of your order.

4. allow 2 - 3 weeks for processing and delivery.

5. enclose this form and the books that are being returned in one envelope, and forward the

envelope to:

Write the serial number of each MV-50 or MV-50W book you are returning with this order form:

______________ ______________ ______________ ______________ ______________

Specify the type and number of books you are ordering, and the amount owed:

o Retail @ $250.00 per book o Wholesale @ $125.00 per book

______________ books @ $_____________ each = $

For return express delivery of books, add $10.00 = $

TOTAL PAYMENT AMOUNT = $

A $35.00 FEE WILL BE CHARGED FOR ALL RETURNED CHECKS!

Facility NumberFacility Name

Address City Zip Code

(Authorized Signature)

(Print Name)

(Business Phone)

(E-Mail Address)

(Date)

(Quantity)

Regular Mail

Bureau of Consumer &

Facility Services

PO Box 2700

Albany NY 12220-0700

Express (FedEx, UPS, Etc.)

Vehicle Safety Services

6 Empire State Plaza, Room 220

Albany NY 12228

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