New York State Department of Motor Vehicles VS-124W (7/08) RENEWAL APPLICATION OF A BODY DAMAGE ESTIMATOR LICENSE FOR OFFICE USE ONLY 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. CIR CIA CID INSTRUCTIONS: 1. 2. 3. This form is for renewals ONLY. Do not use it for original applications. Answer all questions; we will return incomplete applications. 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. Return the completed application with check or money order to: Bureau of Consumer and Facility Services, At tn: Certification Unit, PO Box 2700 - Albany NY 12220-0700; Telephone: (518) 474-7998. 4. 1± 2± CURRENT EXPIRATION DATE: BDE LICENSE NO.: SOCIAL SECURITY NUMBER (as required by the New York State Tax Law) ____ ____ ____ ____ ____ 4± CLIENT IDENTIFICATION NUMBER (from NYS Driver License) ____ ____ ____ ____ Has your name changed in the last three years? Yes 3± ____ ____ ____ ____ ____ ____ ____ ____ ____ No If “Yes”, print your correct name, date of birth and sex in the spaces provided below. If “No”, go to Question 5. LAST NAME 5± FIRST Has your address changed in the last three years? Yes M.I. DATE OF BIRTH Month Day Year SEX Male Female No If “Yes”, print your new address in the spaces provided below. If “No”, go to Question 6. MAILING ADDRESS (Include Street No., Rural Delivery, Box and/or Apt. No.) CITY OR TOWN 6± STATE ZIP CODE COUNTY Have you been convicted of any felony or misdemeanor in the past three years? Yes 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.) Date of Violation Nature of Violation Date of Conviction Disposition & Fine Court Location 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. 7± SIGN NAME IN FULL - DO NOT PRINT - No Nicknames WORK TELEPHONE NO. ± ( DATE ) *VS-124* American LegalNet, Inc. www.FormsWorkFlow.com