New York State Department of Motor Vehicles MV-65 (9/11) VEHICLE ESCORT DRIVER APPLICATION PLEASE PRINT WITH BLUE OR BLACK INK IN THE BOXES www.dmv.ny.gov Note: To become a certified vehicle escort driver, you MUST: l Have a valid driver license l Pay a $40 fee l Be at least 21 years old l Pass a written exam Action Wanted: o Original Certification o Renewal l Present proof of ID (as listed on ID-44) o Replace Certificate o Amend Certification Note: If you are a New York licensed driver and need to change your name and /or address, you must notify DMV of any change BEFORE you submit this application to the Bus Driver Unit. If you are applying for a replacement or need to change your name and/or address on your certificate, complete this form and mail it to: NYS Department of Motor Vehicles, Bus Driver Unit, 6 Empire State Plaza, Room 220C, Albany, New York 12228. A $5.00 check (payable to the Commissioner of Motor Vehicles) is required for a replacement certificate. If you are applying for a renewal, complete this form and mail it to: Department of Motor Vehicles, 207 Genesee Street, Utica, NY 13501-2874. A $40 check (payable to Commissioner of Motor Vehicles) is required for a renewal. Name of Applicant (Last, First, Middle) Phone Number (Include area code) Month State/Province of driver license Day Height Sex Date of Birth Year M o FEET F o Eye Color INCHES Client ID number as it appears on your NYS Vehicle Escort card (if available) Driver License Number Address Where You Get Your Mail (Include Street Number and Name, Rural Delivery, and/or Box) City or Town State Apt. # Zip Code County Address Where You Live - If different from your mailing address (Include Street Number and Name, Rural Delivery, and/or Box) City or Town State Address Change for: Does any of the information on your Escort Certificate have to be changed? o Yes Apt. # o No Zip Code o Mailing Address County o Legal Address Name Change: Print your former name exactly as it appears on your escort certificate Other Change: What is the change and the reason for it ( wrong date of birth, etc.)? I state that the information I have given on this application is true to the best of my knowledge. I certify that I am the holder of a valid driver license that is not now suspended or revoked, and that I have not lost my privilege to drive in New York State. SIGN HERE ç ___________________________________________________________ (Sign name in full - A married woman must use her own first name.) DMV USE ONLY Expiration Date Fee Proof Submitted: o Driver License/ID Approved By Office Date: American LegalNet, Inc. www.FormsWorkFlow.com