Fillable Printable Form VS-121W - Renewal of Certification as a Motor Vehicle Inspector - New York

Form VS-121W - Renewal of Certification as a Motor Vehicle Inspector - New York

APPLICATIONFORRENEWALOFCERTIFICATION

AS A MOTOR VEHICLE INSPECTOR

NOTE: Complete and return so that you receive your

new card before your current card expires.

INSTRUCTIONS:

1. This form is for renewals ONLY. Do not use this form for original applications. If your expiration date is more than

six months passed, you must complete a VS-120 form.

2.Answer all questions; we will return incomplete applications.

3. The three-year certification fee is $15. Make check (no starter checks) or money order payable to the Commissioner

of Motor Vehicles and attach it to this application.

4.Submit completed application with check or money order to: Bureau of Consumer and Facility Services,

Attn: Certification Unit, PO Box 2700 - Albany NY 12220-0700; Telephone: (518) 474-7998.

FOR OFFICE USE ONLY

CIR CIA CID

VS-121W (10/15)

*VS-121W*

CERTIFICATION NO.: CURRENT EXPIRATION DATE:

SIGN NAME IN FULL - DO NOT PRINT - NO NICKNAMESDAYTIME TELEPHONE NO.

( )

DATE

Have you been convicted of any felony, misdemeanor or improper motor vehicle inspection in the past three years?oYes oNo

If “Yes”, give details below:

(Applicants will not necessarily be rejected because of a conviction record. Each application will be reviewed on an individual basis.)

Date of

ViolationNature of Violation

Date of

ConvictionDisposition & FineCourt Location

LAST NAME

MAILING ADDRESS (Include Street No., Rural Delivery, Box and/or Apt. No.)

Has your address changed in the last three years?oYes oNo

MAILING ADDRESS STREET NAME

CITY OR TOWN STATEZIP CODE COUNTY

FIRSTM.I.DATE OF BIRTH

Month Day Year

SEX

Male Female

Section 303(a) of the Vehicle & Traffic law provides for the certification of motor vehicle inspection personnel. The holder of

this certificate agrees to comply with the rules and regulations promulgated by the Commissioner of Motor Vehicles. Failure

to comply or to notify this office of any future change in your address may result in the revocation of this certification.

FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW.

CLIENT IDENTIFICATION NUMBER (from NYS Driver License or Non-Driver ID)

NOTE: Failure to provide a valid Client ID will prevent issuance of a Body Damage Estimator License

____ ____ ____ ____ ____ ____ ____ ____ ____

Check this box if you do not currently have a NYS

Driver License or Non Driver ID. A form (ID-5 VSBDE)

will be mailed to you with instructions on how to obtain

a Client ID.

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