1.2.3.4.5.6. Inspection Stations or Dealersa) Change in business type (for example, Fleet to Public, Wholesale to Retail, etc.): To: From: b) Change in groups approved for inspection (check the box(es) for the group(s) you want to inspect): VEHICLE GROUPS GROUP (Weights shown are maximum gross weights) 002 2a All motor vehicles that have a seating capacity over fourteen passengers, and all motor vehicles and trailers that have an MGW over 18,000 pounds. 002 2b All semi-trailers. 002 3 All motorcycles. 002 DL Diesel Emissions Testing for all non-exempt vehicles registered in the New York Metropolitan Area. 002 1b All trailers, except semi-trailers, that have an MGW under 18,001 pounds. 002 1a All motor vehicles that have a seating capacity under fifteen passengers, and all motor vehicles, except trailers and motorcycles, that have an MGW under 18,001 pounds. Name Certification Number Expiration Date Number and Street County Business address change:New AddressManufacturer220s Name Model Number Business(es) requesting amendment/duplicate certificate(s) 204 check all that apply:002Repair Shop 002Dealer 002Dismantler 002Itin. Veh. Collector 002Salvage Pool 002Transporter 002Inspection Station 002Boat Dealer 002Scrap Collector 002Scrap Processor 002Mobile Car Crusher 002Other Business name change to: City State Zip Code Number and Street County City State Zip CodeREQUEST FOR BUSINESS AMENDMENT/DUPLICATE CERTIFICATE Present Facility Number Present Facility Name Facility Phone Number( ) c) If you will perform diesel emissions inspections, print the manufacturer220s name and the model number of the testing equipment here. This information isrequiredin order to process your request.d) Please provide the name(s) and certification number(s), including expiration date, of your Certified Inspector(s). Use additional sheet(s) if necessary. This information is requiredin order to process your request.MV-253G (2/19)PAGE 1 OF 2dmv.ny.gov Old Address Requested change: 002Amendment 002Duplicate Reason: INSTRUCTIONSUse this form to tell DMV about an amendment or to request a duplicate Business Certificate (you must fill out an originalapplication if you areacquiring a business). There is no fee for amendments or duplicate certificates. If you are making a change, please call (518)474-0919 for information about required documentation.Failure to provide all documentation will delay processing of your request.D UPLICATE C ERTIFICATE C USTOMERS : Complete items 1, 2, 3, 9 and 10 and the 215Certification216 section at the bottom of page 2.A MENDMENT C USTOMERS :Complete items 1, 2, 3, 9 and 10 and the 215Certification216 section at the bottom of page 2. Also, complete items 4 - 8only if they apply to the change you are making.DOCUMENTATIONREQUIREMENTSFORAMENDMENTCUSTOMERSONLYD ISMANTLERS :All dismantlers must provide a letter of zoning approval with this request. New York City Only - all 215Secondhand Dealer - General216, and215Secondhand Dealer - Auto216, amendment requests MUST INCLUDEa Fire Department permit and an NYC Department of Consumer Affairs License.C USTOMERS MAKING LOCATION CHA NGES :If you are changing location, complete Form VS-19 (215Statement of Ownership and/or Permission toUse Place of Business216) and submit it with this request. Repair shopsmust also provide a Certificate of Occupancy, local license or townletter as proof of zoning approval. If the newlocation was previously registered as a Repair Shop, please tell us the Facility number or Facilityname of that shop. This can be used as proof of zoning.D EALERS :All dealers (excluding those who are exempt under the law) are required to have a bond. If you are a dealer requesting anamendment, please call (518) 474-0919 to determine if you have to provide a revised bond with your request. If you are a franchised dealerrequesting an address change, you must provide franchise papers showing the new address.RETURNTHISCOMPLETEDREQUEST, ANDANYREQUIREDDOCUMENTATION, TO:Bureau of Consumer and Facility Services, Application Unit, PO Box 2700, Albany NY 12220-0700 American LegalNet, Inc. www.FormsWorkFlow.com I certify that I am the owner, partner or officer of the business named in this request form, and that the information contained in it is true.NOTE: For partnerships, each partner must sign this form.Name (Please Print Full Name)Business Phone Number( )Signature (Full Name)TitleDatePartner220s Signature (Full Name)Partner220s Signature (Full Name) Name Date of Birth Conviction Date Penalty Deletions to Owners, Partners, Corporate Officers and/or Stockholders holding more than 10% of stock. Use additional sheet(s) if necessary. Additions to Owners, Partners, Corporate Officers and/or Stockholders holding more than 10% of stock. Use additional sheet(s) if necessary.7.8.9.10. a) Have you, or has any person named in this application, ever been an individual owner, partner, interested party, officer, corporation director or stockholder having more than ten percent of the stock in a business for which a DMV license, registration or certification was denied, suspended or revoked in New York State, including matters now on appeal? 002Yes 002Nob) Are you, or is anyone named in this application, scheduled for a hearing which could result in the suspension, revocation or denial of a DMV business license, registration or certification? 002Yes 002Noc) If (a) or (b) is 215YES 216, provide name and address of the person(s), business type, date and action taken against the business or reason for the hearing.Has the owner, any member of the partnership, interested party, officer or director of the corporation been convicted of, or forfeited bail for,any misdemeanor or felony? 002Yes 002No If 215YES 216, give the following information:MV-253G (2/19) Court Nature of Offense CERTIFICATION (a) Name (First, MI, Last)Date of BirthTitlePlease Sign Name in FullDriver License Identification Number Social Security NumberResidence Address Apt. No.Residence Phone( ) (b) Name (First, MI, Last)Please Sign Name in FullResidence Address Apt. No.Residence Phone( ) (c) Name (First, MI, Last)Please Sign Name in FullResidence Address Apt. No.Residence Phone( ) (a) Name (First, MI, Last)Please Sign Name in FullResidence Address Apt. No.Residence Phone( ) (b) Name (First, MI, Last)Please Sign Name in FullResidence Address Apt. No.Residence Phone( ) (c) Name (First, MI, Last)Please Sign Name in FullResidence Address Apt. No.Residence Phone( ) % of Stock or Ownership Date of BirthTitleDriver License Identification Number Social Security Number% of Stock or Ownership Date of BirthTitleDriver License Identification NumberSocial Security Number% of Stock or Ownership Date of BirthTitleDriver License Identification Number Social Security Number% of Stock or Ownership Date of BirthTitleDriver License Identification Number Social Security Number% of Stock or Ownership Date of BirthTitleDriver License Identification Number Social Security Number% of Stock or Ownership PAGE 2 OF 2 XXXXXXXXXreset/clearPresent Facility Number Present Facility Name American LegalNet, Inc. www.FormsWorkFlow.com