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

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

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

APPLICATION FOR RENEWAL OF CERTIFICATION
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*
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2
CERTIFICATION NO.: CURRENT EXPIRATION DATE:
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1
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3
SIGN NAME IN FULL - DO NOT PRINT - NO NICKNAMES DAYTIME TELEPHONE NO.
( )
DATE
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6
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4
Have you been convicted of any felony, misdemeanor or improper motor vehicle inspection in the past three years? o Yes o No
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.)
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5
Date of
Violation Nature of Violation
Date of
Conviction Disposition & Fine Court Location
LAST NAME
MAILING ADDRESS (Include Street No., Rural Delivery, Box and/or Apt. No.)
Has your address changed in the last three years? o Yes o No
MAILING ADDRESS STREET NAME
CITY OR TOWN STATE ZIP CODE COUNTY
FIRST M.I. DATE OF BIRTH
Month Day Year
SEX
Male Female
oo
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.
o
reset/clear
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