Private Inspection Facility License Application Form. This is a New Jersey form and can be use in Motor Vehicle Commission Statewide.
Tags: Private Inspection Facility License Application, New Jersey Statewide, Motor Vehicle Commission
New Jersey Motor Vehicle Commission Trenton, New Jersey 08666 STATE OF NEW JERSEY Business License Services (609) 292-6500 ext.5014 Enclosed are the applications necessary for the issuance of a PRIVATE INSPECTION FACILITY (PIF/PFF) LICENSE. Please ensure that all of the items below are returned for the processing of a license. A copy of your driver license Initial Application Supplementary Application Child Support Certification Sticker Identification card License fee $270.00 (make check payable to MVC) License Certification Form Copy of corporate papers (if applicable) Original Certificate of Insurance in the amounts of $300,000 bodily injury and $50,000 property damage. The certificate holder should read: MVC-PIF Section P.O. Box 170 Trenton, NJ 08666 Color photo of each officer, owner, partner or corporate officer Fingerprint (See attached instruction letter) Business hours Equipment confirmation Copy of equipment lease/purchase PIF emission inspector certificate form Copy of the emission inspector(s) license(s) for your facility Copy of Certificates listed below: A. NJ Sales Tax Identification B. NJ Unemployment Registration C. Federal Employer Identification If you have any questions, please contact us at the phone number listed above. American LegalNet, Inc. www.FormsWorkFlow.com BLC-65 (R 01/08) Business License Services PO Box 171 Trenton, New Jersey 08666-0171 Motor Vehicle Commission APPLICATION FOR LICENSE FOR OFFICE USE ONLY License No. Date Reg. No. Email Approved by The undersigned hereby applies for the license(s) checked in Part 3 and submits the following certified statement: Corp Code 1. Business phone Name of Business (if corporation, corporate name) ____________________________________________________________________ Trade Name 2. Please Check [ ] Corporation Street Address [ ] Other Zip Code City County All applicants please provide the following information and attach copies of proof thereof: A. NJ Sales Tax Identification Number B. NJ Unemployment Registration Number C. Federal Employer Identification Number 4. Complete the following for proprietor, partners, or corporate officers: Name 5. Title 3. Please Check appropriate Box for License: [ ] Leasing Company [ ] Driving School [ ] Moped Dealer [ ] Junkyard [$ ] Private Inspection Facility [ ] Fleet Fleet Inspection Facility [ ] Other Home Address [ [ [ [ [ ] New & Used Motor Vehicle Dealer ] Auto Body Repair Facility ] Used Motor Vehicle Dealer ] Fleet DEIC ] DElC Telephone Number Have the owners, partners, or officers ever been arrested, charged or convicted of a criminal or disorderly persons offense in this or any other state? [ ]Yes [ ]N o 6 [ ]Proprietorship [ ] Partnership if yes, explain: Do you knowingly intend to employ a person who has been convlcted of the above, or any other crime or who was previously licensed as any in this or any other state and was subject to license suspension or revocation? Of the above [ ]Yes [ ]No 7 Give name and address of person Have the owners, partners or corporate officers ever held any of the above licenses? [ ] Yes [ ]N o If yes, please explain the type of license and license numbers American LegalNet, Inc. www.FormsWorkFlow.com Was the license ever suspended or revoked? 8. [ ]Yes [ ]N o If yes, explain: Have the owners, partners or corporate officers, agents or employees of your organization ever used an alias or been known by any other name 9. [ ]Yes If yes, explain: [ ]N o 10. Does any stockholder own more than 10% of the corporation's stock? If yes, give name, address and holding [ ] Yes [ ]N o 11 Attach copy of the Certificate of Incorporation/Formation which has been filed with the N.J. Secretary of State. Foreign Corporations must submit a copy of their Authorization to do business in New Jersey as a Foreign Corporation in addition to a copy of their corporate/formation papers. Place of Incorporation/Formation Date of Incorporation/Formation Date of authorization to do business in New Jersey 12 The applicant certifies all information contained herein is true and agrees any untruthful representation and any violation of the applicable statutes and regulations promulgated by the Commission shall be reasonable and proper grounds for license suspension or revocation. He further agrees to notify the Commission immediately of any change in the status of the business or of any other information which would change the answers and statements in this application or supplement thereto. 13 The individual(s) signing this application certify that they have read the applicable statutes and are thoroughly familiar with the details and penalties provided. I, the undersigned, hereby certify that I _________________of the above business previously named____________________________________________ Owner, Partner, Officer, Member and that the information I have submitted is true to the best of my knowledge. _______________________________________________________________ Print Name of Applicant Signature and Title of Applicant the undersigned, hereby certify that I am Secretary/Member/Partner of the above Corporation and have witnessed the signature of__________________________ who is of said corporation. President, Vice-President or Member Signatureof Secretary/Member/Partner APPROVAL CERTIFICATE Clerk of the Municipality of County of (Print Name) State of New Jersey, hereby certify that the Municipal Governing Body or Zoning Commission has approved the location. establishment and maintenance of the business checked below: [ ] Leasing Company [ ] Fleet DElC [ ] Driving School [ ] New & Used Motor Vehicle Dealer [ ] Moped Dealer [ ] Auto Body Repair Facility [ ] Other [ ] Junkyard [ $ ] Private Inspection Facility [ ] Used Motor Vehicle Dealer [ ] Fleet Inspection Facility [ ] DElC located at Complete Address _____________________________________________________ Print Name of Municipal or Zoning Board Clerk BLC-183 (R12/04) Signature of Municipal or Zoning Board Clerk Date American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS LICENSE SERVICES SUPPLEMENTARY APPLICATION BUSINESS NAME BUSINESS PHONE # 1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX, IF ANY 2. STREET ADDRESS CITY STATE HOME PHONE # 3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS? 4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU W E R E IN EACH STATE OR COUNTRY. 5. DATE OF BIRTH (MO. DAY, YEAR) 7. SEX 6. PLACE OF BIRTH: (CITY, STATE OR FOREIGN COUNTRY) 8. HEIGHT 11. SOCIAL SECURITY NUMBER 10. COLOR OF EYES 9. WEIGHT 12. DRIVER LICENSE NUMBER (STATE) 13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE, VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS? YES NO IF YES, ATTACH EXPLANATION DESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE. 14. I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE: DATE 1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX. IF ANY 2. STREET ADDRESS CITY STATE 3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS? HOME PHONE # 4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU WERE IN EACH STATE OR COUNTRY. 5 DATE OF BIRTH (MO. DAY, YEAR) 7. SEX 11. SOCIAL SECURITY NUMBER 6. PLACE OF BIRTH: (CITY. STATE OR FOREIGN COUNTRY) 8. HEIGHT 9. WEIGHT 10. COLOR OF EYES 12. DRIVER LICENSE NUMBER (STATE) 13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE, VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS? YES NO IF YES, ATTACH EXPLANATIONDESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE. 14. I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE: BLC-205B (R12/03) DATE American LegalNet, Inc. www.FormsWorkFlow.com Business Licensing Services Bureau P.O. Box 171 Trenton, New Jersey 08666-0171 (609) 292-6500 #5014 _______________________________________________________________________________________ CHILD SUPPORT CERTIFICATION FORM _________________________________________ Business Name _________________________________________ Applicant’s Name (Print) __________________ Date of Birth _________________________________________ Social Security Number Under the provisions of N.J.S.A. 2A:17-56.7 et seq., responses to the questions listed below are required. Misstatements will be just cause to take administrative action including, but not limited to, denial of licensure, immediate suspension or revocation of the license. 1. Do you have a child support obligation? Yes No 2. If yes, do the arrearage amounts equal or exceed the amount of child support payable for six months? No Yes 3. Are you subject to a child-support warrant? Yes No I certify that the foregoing responses made by me are true and I am aware that the making of false statements may subject me to contempt of court. ______________________________________________ __________________ Signature Date BLS-43 (R 9/09) On the Road to Excellence www.njmvc.gov New Jersey is an Equal Opportunity Employer American LegalNet, Inc. www.FormsWorkFlow.com Motor Vehicle Commission Trenton, New Jersey STATE OF NEW JERSEY BUSINESS LICENSING SERVICES BUREAU TO ALL MOTOR VEHICLE PRIVATE INSPECTION FACILITIES The New Jersey Motor Vehicle Commission has now established a live fingerprint scan process to streamline criminal background checks required as a condition of certification as a licensed Motor Vehicle Private Inspection Facility. As part of the Business License application process, it is required that all proprietors, partners and corporate officers schedule an appointment with the State fingerprint scan vendor MorphoTrak (formerly Sagem Morpho, Inc.) All you need do is call this toll free number 1-877-503-5981 (English or Spanish Operators) or TTY-1-800-673-0353 (HEARING IMPAIRED Modem Required) to arrange an appointment to be scanned at an established site. When scheduling your appointment, you will be asked to provide certain personal information including your driver’s license and social security number. Please make sure you have this information available when scheduling your appointment. In addition, you will be asked to provide the following Motor Vehicles identification numbers: ORIGINATING AGENCY REFERRAL NUMBER (ORI) NJ920530Z AGENCY CASE NUMBER (Your Driver License Number) CATEGORY MVK RS1 DOCUMENT TYPE STATUTE 39:8-45 MOTOR VEHICLE INSPECTION STATION LICENSING Please complete the applicant information form contained on the back of this letter. Though certain information is already filled in, you will need to supply certain personal information in blocks 9 through 26 as well as your driver’s license number in block 7 which will be used as your agency case number. Please have this form filled in and present it when you appear for your appointment along with the proper photo identification as noted on the back of this letter. After supplying this information you will be scheduled for an appointment at one of the electronic scan sites. When fingerprinted, you will be required to pay a one-time fee in the amount of $51.00 incorporating all required background checks. Payment must be made by certified check or money order made out to the name of the State contractor: MorphoTrak If you have any questions concerning this procedure, please contact the following area: NEW JERSEY MOTOR VEHICLE COMMISSION BUSINESS LICENSING SERVICES BUREAU PRIVATE INSPECTION FACILITY SECTION 609-292-6500 ext.5014 PLEASE BRING THIS LETTER AND PHOTO IDENTIFICATION WITH YOU WHEN YOU APPEAR TO BE FINGERPRINTED American LegalNet, Inc. www.FormsWorkFlow.com . www.bioapplicant.com/nj Formerly Sagem Morpho Inc (1) Originating Agency Number (ORI #) (2) Category (3) Statute Number 39:8-45 MVK NJ920530Z (4) Reason for Fingerprinting (5) Document Type MOTOR VEHICLE INSPECTION STATION LICENSING (7) Contributor’s Case # (Unique Identifier) PRIVATE INSPECTION FACILITY (9) First Name (10) MI (12)Daytime Phone Number ) $51 (8) Miscellaneous DL# ( RS1 (6) Payment Information (13) Social Security Number (11) Last Name (14) Date of Birth (15) Height (16) Weight - (17) Maiden Name (if married female) (18) Place of Birth (U.S. State –for US Citizen; Country for all others) (19) Country of Citizenship (20) Home Address Address (21) Gender (Select one) (22) Hair Color (Indicate most predominant color, one only) Male ( ) Female ( ) Both ( ) (25) Occupation City (23) Eye Color State Zip (24) Race (Select One) A Asian/ Pacific Islander ( includes Asian Indian) B Black W White ( Includes Hispanic/ Spanish Origin) U Unknown I American Indian / Alaska Native (26) Employer (Name) Employer Address City State Zip APPLICANT INFORMATION – READ THIS FORM CAREFULLY AND FOLLOW ALL INSTRUCTIONS TO COMPLETE THE FINGERPRINT PROCESS. You MUST present this completed form at your appointment to be FINGERPRINTED. NO EXCEPTIONS ALLOWED. Applicants without forms or with incomplete forms will not be printed. IDENTIFICATION IS REQUIRED- ACCEPTABLE ID REQUIREMENTS –ID MUST include Photo, Name, Address (Home/ Employer) and Date of Birth. Acceptable ID MUST be issued by a Federal, State, County or Municipal entity for Identification purposes. Examples of acceptable ID are: 1) Valid Photo Drivers License or Valid Photo ID issued by any State DMV or NJ MVC, 2) Passport. Acceptable ID MUST meet all of the underlined requirements above and MUST be present on one (1) ID. Combinations of documents are NOT acceptable. If acceptable ID is not presented you will not be fingerprinted. For applicants who are required to pay for their own fingerprinting fees, payment is required at the time of scheduling. Payment may be made with a credit card or electronic debit from a checking account. Remember your account will automatically be debited. An $11 fee is charged to cover the cost of a scheduled appointment for applicants who do not cancel/reschedule by noon on the business day prior to your scheduled appointment (Saturday noon for Monday appointments). All appointments can be canceled/rescheduled via the web without penalty if cancellation requirements are met. The $11 fee will also apply for applicants who are turned away from the printing sites due to the inability to present proper ID, who fail to present this completed Universal Fingerprint Form provided to you by your requesting agency or employer, or who are turned away because information on this form does not match the information provided during the scheduling process. You will be refunded State and Federal search fees only. Appointment scheduling is available via the web at www.bioapplicant.com/nj, 24 hours per day, 7 days per week. For applicants who do not have web access, appointments can be made by contacting us toll free at (877) 503-5981 on a first call, first served basis Monday through Friday, 8:00 AM to 5:00 PM EST and Saturday, 8:00 AM to 12 noon EST. English and Spanish speaking operators are available. Hearing impaired scheduling is available at (800) 673-0353. ONLY applicants who schedule through the call center can make payment by money order at the fingerprint site. No other form of payment is accepted at the fingerprint site. Your APPLICANT ID, Site, Date, Time of your appointment, and payment authorization will be confirmed by the call center agent or web confirmation when scheduling is complete. You must record this information in the appropriate blocks below while speaking with the operator. If you appear for fingerprinting at a site where you are not scheduled or on a different date and time, you will be turned away and not fingerprinted. If applicable, you may incur the $11 appointment fee. Your PCN number will be recorded when your fingerprinting has been completed. You MUST retain a copy of the form and a copy of the receipt provided to you by the Fingerprint Technician for your records. NO RECEIPTS WILL BE PROVIDED AFTER THE DATE OF PRINTING. Applicant ID No. Scheduled Site/ Date/ Time Agency Information #1 PYMT Authorization PCN Agency Information #2 APPLICANTS MUST NOT ALTER, SHARE, OR REUSE THIS FORM FORM NO. NJAPS2, Version 4.0 September 1, 2009 American LegalNet, Inc. www.FormsWorkFlow.com New Jersey Motor Vehicle Commission Office of Regulatory Affairs Business License Services P.O. Box 170 Trenton, New Jersey 08666-0170 BUSINESS HOURS Name of Business___________________________________ License No. ___________________________ Address_________________________________________________________________________________ Days Open for Business Business Hours Monday From To Tuesday From To Wednesday From To Thursday From To Friday From To Saturday From To Signature of Proprietor, partner or officer_____________________________________________________ Date____________________________ MM BLC-86A (R12/03) American LegalNet, Inc. www.FormsWorkFlow.com NEW JERSEY MOTOR VEHICLE COMMISSION CERTIFICATION This is to certify that I understand the license for which I am making an application may be issued prior to the standard investigation, to include character investigation and facility compliance. It is, therefore, understood that should any derogatory or disqualifying information be received subsequent to the issuance of the license, I will immediately and voluntarily surrender all items issued. Signed: Proprietor, Partner or Corporate Officer Business Name BLC-79 (R7/03) Date American LegalNet, Inc. www.FormsWorkFlow.com Motor Vehicle Commission DEIC/PIF NAME LICENSE NO. I have purchased and installed a State of New Jersey approved: Make Model No. Serial No. Analyzer . Dynomometer Opacity Meter The following designated Inspectors have been trained in the use of: Analyzer Dynomometer Opacity Meter LICENSEE'S SIGNATURE MVC REPRESENTATIVE'S SIGNATURE MVC SUPERVISOR'S SIGNATURE SS-34 (R12/03) American LegalNet, Inc. www.FormsWorkFlow.com Vehicle Commission TRENTON, NEW JERSEY 08666 STATE OF NEW JERSEY Business License Services (609) 292-6500 ext.5014 P.I.F. EMISSION INSPECTOR CERTIFICATION P.I.F. License # Business Name I, the undersigned, certify that the below listed ernployee(s) are licensed as P.I.F. Emission Inspectors. Name Address lnspector License # Licensee‘s Name & Title Date MVC Investigator’s Signature & ID# Date MVC Supervisor’s Signature & ID# Date ATTACH COPY OF THE CERTIFICATION(S) New Jersey Is An Equal Opportunity Employer BLC-92(R 01/08) American LegalNet, Inc. www.FormsWorkFlow.com NEW JERSEY ELECTRONIC TRANSMISSION SERVICE ENROLLMENT FORM This form must be filled out completely and returned in order for a station to be activated for the NJ Enhanced Emissions program that begins December 10, 1999. This enrollment form must be received by MClW prior to the initiation of Electronic Transmission (ET) service, and anytime thereafter if there is a change in Station or Billing information. Please type or print legibly. Detailed instructions for filling out this form are included. If you have any questions, call MCI WorldCom toll-free at 1-877-365-2277. Return the completed form to the address listed below to initiate your ET service: MClWorldCom Attn: NJ-EMIS P.O. Box 34280 Phoenix, A2 85067-4280 Check ✔ all boxes that apply New Inspection Station Change in Owner Information Change in Inspector Information Re-Appointment Change in Billing Information Change of Authority Change in Station Information Change in Analyzer Information I (a) Inspection Station Number: (b) Station Name: (c) Optional Station Description for Invoice: City or Town Number and street County Zip Code State (d) Address: First Middle Last (e) Contact Area Code (f) Phone: ( Phone Number Extension ) Area Code (g) FAX: ( Phone Number ) If the Owner Information is the same as Section Two, continue to Section Four. Youmust fill out this Section if the Owner Information is different from Station Information entered in Section Two. Check ✔ only one box Is this Owner responsible for more than one station? YES NO (a) Business Name: Number and street City or Town County State Zip Code (b) Address: First Middle Last (c) Contact Area Code (d) Phone: 09/10/99 ( Phone Number ) Area Code Extension (e) FAX: ( Phone Number ) American LegalNet, Inc. www.FormsWorkFlow.com Check ✔ o n l y one box Send the invoice to: Check✔o n l y one box Is this Bill Payer responsiblefor more than one station? the Station as specified in Section Two. Continue to Section Five. the Owner as specified in Section Three. Continue to Section Five. Other Billing Location. Fill out this Section. YES NO (a) Business Name: Number and street City State Zip Code (b) Address: Middle First Last (c) Contact: Area Code (d) Phone: ( Phone Number ) Extension Area Code (e) FAX: ( Phone Number ) Inspector Name: License Number: Inspector Name: License Number: Inspector Name: License Number: Inspector Name: License Number: Inspector Name: License Number: Enter Analyzer Unit Number and its telephone number. Each analyzer must have a dedicated telephone number. Analyzer Unit Number: Telephone Number: ( ) Analyzer Unit Number: Telephone Number: ( ) Analyzer Unit Number: Telephone Number: ( ) Analyzer Unit Number: Telephone Number: ( ) 09/10/99 American LegalNet, Inc. www.FormsWorkFlow.com NEW JERSEY ELECTRONIC TRANSMISSION SERVICE TERMS AND CONDITIONS Business Agreement. Use of the New Jersey Electronic Transmission communication service constitutes agreement to the following terms and conditions. MCI may deactivate Customer’s access to the MCVET Network at any time should Customer fail to abide by the terms of this Agreement. Description of Service. MCI Worldcom will provide to Customer, and Customer will receive from MCI, access to the Network (“MCI Services”) Tariff FCC provided pursuant to this Agreement and MCI Tariffs FCC No. and 8, No. 27, and any other applicable interstate and international tariff of MCI and its affiliates, each as supplemented by this Agreement, and intrastate telecommunications services provided pursuant to MCI’s state tariffs and price lists, as applicable, governing such services (the “Tariff). This Agreement incorporates by reference the terms of each such tariff. MCI may modify its Tariff from time to time in accordance with the thereby affect the furnished Customer. In the event of a conflict or inconsistency between this Agreement and any tariff, the terms and conditions of the Tariff shall govern. Implementation. MCI will complete its checklist of Customer’s service requirements and make the initial connection to the MCVET Network. Customer Responsibilities. (a) Should any unauthorized user obtain access to the Customer must notify the MCI designated Analyzer System (“ANALYZER) Call Center immediately. Until such notification is made, Customer understands and agrees that Customer will continue to be responsible to pay for all transactions and transmissionsincurred on the ANALYZER Customer understands and agrees that Customer shall be responsible for any (b) access code andor personal information number (PIN) that may be associated with should not be access into the MCVET Network. Customer’s access shared and must be kept secure. MCI shall in no way be liable for transaction charges fraudulently incurred on the ANALYZER unit. It is the Customer’s responsibility to pay these transaction charges. Customer shall notify the MCI Customer Service Center immediately upon (c) any address change, or Customer departure from Customer’s listed address. Changes to Customer account can only be made by Customer. Customer understands and agrees that Customer shall be responsible for (d) obtaining from the New Jersey Division of Motor Vehicles an inspection station certificate of appointment to provide emissions tests. Failure to obtain or maintain test equipment in good working order or loss of Customer’s certificate of appointment will prevent access to the MCVET Network. Warranty Disclaimer and Limitation of Liability. (a) MCI SERVICES PROVIDED HEREUNDER ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR NON-INFRINGEMENT OF THIRD PARTIES RIGHTS. FURTHER, MCI DOES NOT WARRANT, GUARANTEE, OR MAKE ANY REPRESENTATIONS REGARDING THE USE, OR THE RESULTS OF THE USE OF MCI SERVICES OR WRITTEN MATERIALS IN TERMS OF CORRECTNESS, ACCURACY, RELIABILITY, OR OTHERWISE. CUSTOMER UNDERSTANDS THAT MCI IS NOT RESPONSIBLE FOR AND WILL HAVE NO LIABILITY FOR HARDWARE, SOFTWARE OR OTHER ITEMS OR ANY SERVICES PROVIDED BY ANY PERSONS OTHER THAN MCI. Neither party shall be deemed negligent, at fault or liable in any respect to the (b) other for any delay, interruption or failure in performance hereunder resulting from fire, flood, water, the elements, explosions, acts of God, war, accidents, labor disputes, strikes, shortages of equipment or suppliers, unavailability of transportation or other cause heyond the reasonable control of the party delayed or prevented from performing. MCI’s liability for willful misconduct, if established as a result of judicial or administrative proceedings, is not limited by these Service Terms and Conditions. IN NO EVENT SHALL EITHER PARTY BE LIABLE TO THE OTHER FOR ANY INDIRECT, INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES, INCLUDING LOSS OF REVENUE AND PROFITS, EVEN IF AWARE OF THE POSSIBILITY THEREOF. Cancellation Rights and Liabilities. Either party may terminate this Agreement with thirty (30) days prior written notice to the other party. However, MCI may terminate this Agreement immediately, without liability, upon notification and direction of the New Jersey Division of Motor Vehicles. Termination for Cause. In addition to any other rights of cancellation specified herein, either party may terminate this Agreement upon three (3) days prior written notice to the other in the event of the other’s failure to pay any amounts due hereunder and not duly contested in good faith within ten (10) days after the receipts of the terminating party’s written notice of default concerning the same; or the other’s failure to cure a material breach within thirty (30) days after receipt of the terminating party’s written notice of default concerning the same. Charges and Payment Terms for MCI Services. (a) By using the MCI Service, Customer assumes full responsibility for all transactions and transmission charges incurred by the ANALYZER and its associated telephone number related to emission testing and diagnosticand repair information. per test for use Customer shall pay one dollar and forty-seven cents (b) of the MCI Services provided by MCI. The standard test will consist of an initial test call and an end of test call. Customer shall be responsible for any emission related diagnosticand repair information charges as well. transaction, MCI will invoice Customer and the charges shall be due and payable on the (c) due date as indicated on the invoice. The invoice shall state the total number of test transactionsand the total amount due. Customer shall pay all charges arising under this Agreement, by the invoice due date. Failure to pay the MCI invoice on or before the due date may result in Customer being denied access to the MCVET Network until such payment is received by MCI. If Customer does not provide MCI written notice of a dispute with respect to MCI’s charges within six (6) months from the date the invoice was rendered, such invoice shall be deemed to be correct and binding to the Customer. Customer agrees that there will be a Twenty-Five Dollar ($25.00) fee for any (d) payment to MCI that is returned due to insufficient Failure to pay the outstanding invoice in addition to the Twenty-Five Dollar ($25.00) fee within ten (10) days of notification may result in an ANALYZER lockout of service. Applicable Law. Customer understandsthat MCI, in conducting its business in the manner set forth herein, is subject to the CommunicationsAct of 1934, as amended, and as interpreted and applied by the Federal CommunicationsCommission. Otherwise, and where not inconsistent with the CommunicationsAct of 1934, this Agreement shall be construed in accordance with the laws of the State of New Jersey. Customer will comply with all applicable state and federal laws. Assignment. Neither party may assign this Agreement or any of its rights hereunder, without the prior written consent of the other party, which consent shall not be unreasonably withheld, except MCI may assign this Agreement to any parent, subsidiary, affiliate or purchaser of all or substantiallyall of its assets. Independent Contractors.The relationship between the parties shall not be that of partners or joint ventures of one another and nothing contained in this Agreement shall be deemed to constitute a partnership agreement between them. Entire Service Order. This Service Enrollment Form and Agreement together with all Exhibits and the Tariff set forth the entire understanding between the parties with regard to the subject matter hereof and supersedes any prior or contemporaneous agreements, discussions, representationsor negotiationsbetween the parties whether written or oral with respect thereto. amendments to this Service Enrollment Form shall be in writing and signed by the authorized representatives of both parties. All notices, requests, demands or communications shall be deemed effective upon personal delivery or on the calendar day following the date of the telex, telegram, or MCI Mail, or when received if sent by registered, certified or express mail I have reviewed this form and believe all information is true and correct. By submitting this signed form, I acknowledge that I have read and understand the "Service Term and Conditions" that are made a part of this agreement. I further acknowledge and accept that these terms will control the operation of this agreement, including the responsibility to pay, in a timely manner. all authorized cost incurred for the ET Services. (b) Date: (a) Authorized Signature: First Last Middle (c) Printed Name: Area Code (d) Title: Page 3 Phone Extension (e) Phone: 09/10/99 10:43 AM MCIEnrollmentForm~3 American LegalNet, Inc. www.FormsWorkFlow.com NEW JERSEY ELECTRONIC TRANSMISSION ENROLLMENT FORM INSTRUCTIONS These instructions are numbered and correspond to each section of the enrollment form. Please read them to ensure your forms are filled out correctly. PLEASE PRINT OR TYPE CLEARLY. INCOMPLETE OR ILLEGIBLE FORMS WILL DELAY PROCESSING OF YOUR APPLICATION COSTING YOUR BUSINESS REVENUE. SECTION ONE Check Boxes Check the box that describes your situation. you are submitting a form that reflects changes in multiple sections, check all the boxes that apply. SECTION TWO STATION INFORMATION Enter information about the physical location of (a)Inspection Station Number Enter the State assigned license number. (b)Station Name Enter the name of the station as registered by the State. (c)Station Description a partnershipor corporation is the responsible bill payer, enter the business's internal station identifier,if needed. This will be displayed on the invoice to facilitate the business's internal example, 326. accounting. station being enrolled (d) Address Enter the complete street address, city, county and state where the station is physically located. (e)Contact Enter the name of a contact that can be reached at the station. Phone Enter the phone number and extension of where the station contact can be reached. Enter the phone number of a facsimile machine that resides at the station. ....................... SECTION THREE OWNER INFORMATION Check Boxes Enter information about the station owner if owner information is different from Section Two. Check YES if the Owner indicated in this Section is responsible for multiple stations. Check NO if the Owner indicated in this Section is only responsible for this station. (a)Business Name a partnershipor corporation owns the station, enter the name of the business or corporation. (b)Address Enter the owner's complete street address, city and state. (c)Contact a partnershipor corporationowns the station, enter a business contact. independently owned, enter the owner's name. the station is (d) Phone SECTION FOUR Enter the phone number and extensionof where the owner contact can be reached. (e) Fax Enter the phone number of the contact's facsimile machine. BILLING INFORMATION MCI will mail one invoice to the location specified i n this Section. Check Box Check if you would like the invoice sent to the contact and address specified in Section Two. this box is checked, you do not need to fill out Section Four. The information specified in Section Two will become your Billing Information. Continue to Section Five. Check OWNER if you would like the invoice sent to the contact and address specified in Section Three. this box is checked, you do not need to fill out Section Four. The information specified in Section Three will become your Billing Information.Continue to Section Five. Check OTHER AGENT if there is an agent other than the Owner or the Station that is the responsible bill payer for charges accrued by the station. You must fill out this Section. Check Box Check YES if the Bill Payer indicated in this Section is responsible for multiple stations. Check NO if the Bill Payer indicated in this Section is only responsible for this station. (a)Business Name a partnershipor corporation is the responsible bill payer, enter the name of the partnershipor corporation, (b)Address Enter the complete street address, city, and state where the invoice should be mailed. (c)Contact Enter the name of the person responsible for paying the invoice. (d) Phone the phone number and extension of where the billing contact can be reached. (e) Fax Enter the phone number of a facsimile machine that resides at the billing address. SECTION FIVE EMISSIONS INSPECTOR INFORMATION Enter the name and license number as found on the license issued by the state for ALL Emissions Inspectors employed at the station. Attach additional sheet if necessary. SECTION SIX ANALYZER INFORMATION Enter the Analyzer Unit Number and dedicated telephone number for each Analyzer located at the station. Attach additional sheet if necessary. SECTION SEVEN TERMS AND CONDITIONS AGREEMENT Theperson who makes business decisions for the station must fill out and sign this section. Theperson who signs i n this Section is legally responsible for ET charges incurred by this Station, even if an alternate Billing Agent has been indicated in Sections Two, Three or Four. (a)Authorized Signature Theperson who makes business decisions for the station must sign here. (b) Date Enter the date of the signature of the authorized person who signed in 7a. (c)Printed Name Clearlyprint the name of the authorized person who signed in 7a. (d)Title Page 4 Print the title of the authorized person who signed in 7a. (e)Phone Enter the phone number and extension of the person who signed in 7a. AM American LegalNet, Inc. www.FormsWorkFlow.com