Fillable Printable Form VS-120 - Motor Vehicle Inspector Certification Application - New York

Form VS-120 - Motor Vehicle Inspector Certification Application - New York

TEST RESULTS

Group(s) 1 2 3

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LAST NAME FIRST M.I.

Month Day YearMale Female

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CIA CIO CIC CIS CIG CID

FOR OFFICE USE ONLY

u FOR ORIGINAL APPLICATIONS: Answer ALL questions on Page 1 and Page 2 that

apply to you, and SIGN the application on PAGE 2 or it will be returned to you for

completion. You MUST be at least 17 years old and have AT LEAST ONE YEAR OF

MOTOR VEHICLE REPAIR EXPERIENCE in the last 5 years immediately preceding this

application, in the area in which you apply to be certified, or you must provide a copy of

an acceptable school diploma in vocational motor vehicle trades. When your application

is approved, DMV will notify you by mail of the date, time and location of the inspector

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

the bottom of page 2 of this form.

u FOR AMENDMENT AND DUPLICATE APPLICATIONS: Answer questions 1-21 and

u 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.

Have you ever applied for or taken a test to become a Certified Motor Vehicle Inspector?oYes oNo

MAILING ADDRESS(Include Street No., Rural Delivery and/or Box No.) HEIGHT EYE COLOR

Feet Inches

HOME TELEPHONE (Include Area Code)

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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.

oCheck 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.

APPLICATIONFORCERTIFICATIONASA

MOTOR VEHICLE INSPECTOR

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Have you ever been a Certified Motor Vehicle Inspector and/or Body Damage Estimator?

oYes oNo If “Yes,” please write your Certification No. ___________________________________

Check type of application:

oORIGINALoAMENDMENT (No Fee) oDUPLICATE (No Fee)

Check all certification groups for which you are applying.

o 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)

o 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)

o Group 3 (Allows an individual to conduct safety inspections of motorcycles)

VS-120 (10/15)

PAGE 1 OF 2

Certificate NumberCounty

CIRCLE ONE:

OE ADD

Note: Check or money order must be attached to

enter OE or ADD

Group(s) 1 2 3

A A A A

Y N

oAddress Change

Has your address changed since your last certification was issued? oYesoNo

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CITY OR TOWN STATE ZIP CODE COUNTY

HOME ADDRESS

(If Different From Mailing Address)

NUMBER AND STREET (Include Street No., Rural Delivery and/or Box No.)

APARTMENT NO. CITY STATE ZIP CODE

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STREET NAMEAPT. NO.

PLEASE CONTINUE, AND SIGN ON PAGE 2.

Please print or type in the open spaces next to the arrows.

DATE OF BIRTH SEX

/ /

*VS-120*

Court Location

Date of Violation

Nature of ViolationDate of ConvictionDisposition & Fine

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FOR ORIGINAL APPLICATIONS ONLY

Have you ever been convicted of any felony, misdemeanor or improper motor vehicle inspection?

oYes oNo 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.)

Describe Type of Repairs Performed (be specific)

Dates (From - To)

Employer’s Name and Address

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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.

Type of CourseDegree, Diploma or Certificate

Dates Attended

School Name and Address

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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.

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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.

u 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 (10/15)

www.dmv.ny.gov

PAGE 2 OF 2

PRESENT EMPLOYER FACILITY NUMBER BUSINESS TELEPHONE NUMBER

( )

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BUSINESS ADDRESS(NUMBER AND STREET) CITY STATEZIP CODE

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SIGNATURE__________________________________________Date_________________

(Sign Name in Full - DO NOT PRINT - No Nicknames)

NAME (PLEASE PRINT)__________________________________________________________

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