Fillable Printable Form VS-124W - Application of a Body Damage Estimator License - New York
Fillable Printable Form VS-124W - Application of a Body Damage Estimator License - New York
Form VS-124W - Application of a Body Damage Estimator License - New York
RENEWAL APPLICATION OF
A BODY DAMAGE ESTIMATOR LICENSE
INSTRUCTIONS:
1. This form is for renewals ONLY. Do not use it for original applications.
2. Answer all questions; we will return incomplete applications.
3. The three-year certification fee is $150. Make check (no starter checks) or money order payable to the Commissioner
of Motor Vehicles and attach it to this application.
4. Return the 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.
SOCIAL SECURITY NUMBER
(as required by the New York State Tax Law)
____ ____ ____ ____ ____ ____ ____ ____ ____
CLIENT IDENTIFICATION NUMBER (from NYS Driver License)
____ ____ ____ ____ ____ ____ ____ ____ ____
FOR OFFICE USE ONLY
CIR CIA CID
VS-124W (10/15)
*VS-124*
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2
BDE LICENSE NO.:
CURRENT EXPIRATION DATE:
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1
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4
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3
SIGN NAME IN FULL - DO NOT PRINT - No Nicknames WORK TELEPHONE NO.
( )
DATE
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7
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5
Have you been convicted of any felony or misdemeanor 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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6
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 name changed in the last three years? o Yes o No
If “Yes”, print your correct name, date of birth and sex in the spaces provided below. If “No”, go to Question 5.
Has your address changed in the last three years?
o Yes o No
If “Yes”, print your new address in the spaces provided below. If “No”, go to Question 6.
CITY OR TOWN STATE ZIP CODE COUNTY
FIRST M.I. DATE OF BIRTH
Month Day Year
SEX
Male Female
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Section 398(d) of the Vehicle & Traffic Law provides for the licensing of motor vehicle body damage estimators. Anyone who
has such a licenses agrees to comply with the rules and regulations promulgated by the Commissioner of Motor Vehicles.
Failure to comply to comply with these rules and regulations may result in the revocation of this license. Notify this office of
any change in your address.
FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW.
NOTE: If you are currently licensed by the Insurance Department, as of
January 1, 1996, you will not have to be licensed by this Department.
If you do not hold an insurance adjustor’s license, complete this form.
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