TEST RESULTSGroup(s) 1 2 3 P P P P F F F F N N N NW W W W Y N N YLAST NAMEFIRSTM.I. Month DayYearMale Female 002 002 CIA CIO CIC CIS CIG CID FOR OFFICE USE ONLY002 FOR ORIGINAL APPLICATIONS: Answer ALL questions on Page 1 and Page 2 that apply to you, and SIGN the application on PAGE 2 or it will be returned to you for completion. You MUSTbe at least 17 years old and have AT LEAST ONE YEAR OF MOTOR VEHICLE REPAIR EXPERIENCEin the last 5 years immediately preceding this application, in the area in which you apply to be certified, or you must provide a copy of an acceptable school diploma in vocational motor vehicle trades. When your application is approved, DMV will notify you by mail of the date, time and location of the inspector training class. You MUST present photo ID at the class as proof of identity. If you have difficulty reading or understanding written material, please contact the office identified at the bottom of page 2 of this form. 002 FOR AMENDMENT AND DUPLICATE APPLICATIONS: Answer questions 1-21 and SIGN in #25. 002 REQUIRED FEES Non-refundable application fee ($10) and three-year certification fee ($15). Make check or money order for $25 payable to the Commissioner of Motor Vehicles. You MUST send your check with this application. Starter checks are not accepted.Have you ever applied for or taken a test to become a Certified Motor Vehicle Inspector?002Yes 002NoMAILING ADDRESS(Include Street No., Rural Delivery and/or Box No.) HEIGHTEYE COLORFeetInches HOME TELEPHONE (Include Area Code)( ) CLIENT IDENTIFICATION NUMBER(From New York State driver license or non-driver ID)NOTE:Failure to provide a valid Client ID number will prevent issuance of a Certified Inspector card.002Check this box if you do not currently have a New YorkState driver license or non-driver ID. A form(ID-5 VSCI) will be mailed to you with instructionson how to obtain a Client ID number. APPLICATIONFORCERTIFICATIONASAMOTOR VEHICLE INSPECTOR3003200340035003600370031003Have you ever been a Certified Motor Vehicle Inspector and/or Body Damage Estimator?002Yes 002No If 215Yes,216 please write your Certification No. Check type of application: 002ORIGINAL002AMENDMENT (No Fee)002DUPLICATE (No Fee)Check all certification groups for which you are applying. 002Group 1 (Allows an individual to conduct safety, diesel emissions, OBDII emissions, and low enhanced emissions inspectionsof motor vehicles that have a seating capacity under fifteen passengers, and motor vehicles and trailers that have a MGWunder 18,001 pounds, except motorcycles and semi-trailers)002Group 2 (Allows an individual to conduct safety and diesel emissions inspections of motor vehicles that have a seatingcapacity over fourteen passengers, motor vehicles and trailers that have a MGW over 18,000 pounds, and semi-trailers,except motorcycles) 002Group 3 (Allows an individual to conduct safety inspections ofmotorcycles)VS-120 (10/15)PAGE 1 OF 2 Certificate NumberCounty CIRCLE ONE: OE ADDNote: Check or money order mustbe attached toenter OE or ADDGroup(s) 1 2 3 A A A A Y N002Address Change Has your address changed since your last certification was issued? 002Yes002No 8003130031500316003CITY002OR002TOWNSTATE ZIP002CODECOUNTYHOME ADDRESS (If Different From Mailing Address)NUMBER AND STREET (Include Street No., Rural Delivery and/or Box No.) APARTMENT NO. CITYSTATE ZIP CODE 14003900312003110031700310003 STREET NAMEAPT. NO.PLEASE CONTINUE, AND SIGN ON PAGE 2.Please print or type in the open spaces next to the arrows. DATE OF BIRTH SEX// *VS-120* American LegalNet, Inc. www.FormsWorkFlow.com Court Location Date of ViolationNature of ViolationDate of ConvictionDisposition & Fine 22003FOR ORIGINAL APPLICATIONS ONLYHave you ever been convicted of any felony, misdemeanor or improper motor vehicle inspection?002Yes 002NoIf 215YES,216 give details below: (Applicants will not necessarily be rejected because of a conviction record. Such applications will be reviewed on an individual basis.)Describe Type of Repairs Performed(be specific) Dates (From - To)Employer220s Name and Address 23003FOR ORIGINAL APPLICATIONS ONLYBy month and year, list the dates of all your motor vehicle repair experience. You must have at least one year of motor vehiclerepair experience in the last five years immediately precedingthe date of this application. Attach additional sheets if necessary. Type of CourseDegree, Diploma or Certificate Dates AttendedSchool Name and Address 24003FOR ORIGINAL APPLICATIONS ONLYList any trade school, vocational school, or other motor vehicle repair courses taken. Only approved schools are acceptable.You must provide a COPYof your diploma if you have less than one year of work experience.25003Section 304(a) of the Vehicle & Traffic Law provides for the certification of motor vehicle inspection personnel. A Certified Inspectoragrees to comply with the rules and regulations promulgated by the Commissioner of Motor Vehicles. Failure to comply with theserules and regulations may result in the revocation of this certification.FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW.002 SEND APPLICATION AND CHECK TO: BUREAU OF CONSUMER AND FACILITY SERVICES Attn: Certification Unit PO Box 2700 Albany NY 12220-0700 Telephone (518) 474-7998NOTE: Notify this office of any change in your address. VS-120 (10/15)dmv.ny.gov PAGE 2 OF 2 PRESENT EMPLOYERFACILITY NUMBERBUSINESS TELEPHONE NUMBER( )18003 BUSINESS ADDRESS(NUMBER AND STREET) CITY STATEZIP CODE210031900320003 SIGNATUREDate(Sign Name in Full - DO NOT PRINT - No Nicknames)NAME (PLEASE PRINT) CLIENT IDENTIFICATION NUMBER(From New York State driver license or non-driver ID)NOTE:Failure to provide a valid Client ID number will prevent issuance of a Certified Inspector card. American LegalNet, Inc. www.FormsWorkFlow.com