Fillable Printable Form VS-95 - Public Emissions Inspection Buy/Sell Agreement - New York

Form VS-95 - Public Emissions Inspection Buy/Sell Agreement - New York

PUBLIC EMISSIONS INSPECTION

STATION BUY/SELL AGREEMENT

*Enclose this form with the Original Facility Application submitted by the purchaser*

In order for DMV to accept for review a buy/sell agreement for an official public emissions group 1a inspection station, the

selling facility and the purchasing facility must be in the same county or within five miles of each other. Additionally, the selling

facility must be in “good standing” at the time of sale. “Good standing” means that:

- the facility license is valid and is not suspended or revoked,

- the facility does not owe any outstanding civil penalties,

- the facility has no hearings or appeals pending before the DMV, and

- the facility has no litigation pending in which the DMV is named as a party.

The selling facility must also be able to account for all unused inspection certificates (stickers).

If inspection certificates are missing, there may be long delays in processing the buy/sell agreement, denial of the

application, or possible administrative action.

Selling Facility Information:

Facility Number: __________________________________ County: ________________________________________

Facility Name: _________________________________________________________________________________

Facility Address: _________________________________________________________________________________

_________________________________________________________________________________

Daytime Contact Phone: (_______) _______-___________ Alternate Contact Phone: (______) ______-___________

NYVIP Unit Number : NY_____________________________

A copy of your

current inspection license issued by DMV must be attached.

I/we understand that if DMV approves the original facility application for a public emissions inspection station that was

submitted by the purchaser, the inspection license for the selling facility will be placed out of business. If the

purchasing facility is approved at the same location as the selling facility, all business types for the selling

facility will be placed out of business. After being placed out of business, if I/we wish to become a public emissions

inspection station in the future, I/we would be required to submit an original application. If I/we apply to become a

public emissions inspection station, the application will be for a new license and, as such, may be subject to placement

on a waitlist, as required by 15 NYCRR 79.7 (f).

I/we, the undersigned, sold or agree to sell the facility below.

I/we understand that ______________________________________________________________________________

is applying to DMV to acquire approval to operate a public emissions group 1a inspection station.

Date of agreement/sale: _______/_______/______________

ALL principals of the selling facility on record with DMV must sign below (attach additional notarized sheet(s) if necessary):

IMPORTANT: This form must be notarized within 90 days prior to receipt by DMV.

(name of purchaser)

(mm) (dd) (yyyy)

Print Name Title(s) Date of Birth Signature

Sworn to and signed before me this ________________day,

in the year of _________________.

_______________________________________________

(Notary Public)

VS-95 (5/15) Page 1 of 2

Notary Stamp Below

/ /

*This form must be notarized within 90 days prior to receipt by DMV.

Purchaser Information:

Name: ________________________________________ Daytime Contact Phone: (_____) _______-______________

Contact Address: _________________________________________________________________________________

_________________________________________________________________________________

Facility Number (if applicable): _______________________

VS-95 (5/15) Page 2 of 2

Computerized Vehicle Inspection System (CVIS):

In addition to transferring the facility licenses and certificates, every official public emissions station needs to have a CVIS.

The current provider of the CVIS in New York State is Opus Inspection. Please contact them regarding transferring equipment

or an original equipment purchase at (866) 623-8378 or at www.nyvip.org.

Print Name Title(s) Date of Birth Signature

Sworn to and signed before me this ________________day,

in the year of _________________.

_______________________________________________

(Notary Public)

Notary Stamp Below

Print Name Title(s) Date of Birth Signature

Sworn to and signed before me this ________________day,

in the year of _________________.

_______________________________________________

(Notary Public)

Notary Stamp Below

Print Name Title(s) Date of Birth Signature

Sworn to and signed before me this ________________day,

in the year of _________________.

_______________________________________________

(Notary Public)

Notary Stamp Below

Print Name Title(s) Date of Birth Signature

Sworn to and signed before me this ________________day,

in the year of _________________.

_______________________________________________

(Notary Public)

Notary Stamp Below

/ /

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