New York State Department of Motor Vehicles MV-653V (1/09) VOLUNTEER FIRE COMPANY OR VOLUNTEER AMBULANCE COMPANY CERTIFICATION OF ELIGIBILITY FOR OFFICIAL PLATES ATTENTION: This form is to be used only by a volunteer fire company or volunteer ambulance company to certify eligibility for Official Plates for the vehicle types described in the check boxes below. The vehicle must be registered in the name of the volunteer organization. THIS FORM CANNOT BE USED TO REGISTER AMBULANCES. Proof of vehicle insurance is required. You must present a valid insurance card with this form. VOLUNTEER FIRE OR VOLUNTEER AMBULANCE ORGANIZATION INFORMATION Name of Volunteer Organization Address Head of Organization Title Business Phone Business E-Mail Address (Optional) DESCRIPTION OF VEHICLE(S) (NO AMBULANCES SHOULD BE LISTED IN THIS SECTION): Check this box if you are certifying multiple vehicles, and attach a separate sheet listing the requested information for all vehicles. Year Make Model Vehicle ID # (VIN) Plate Number (if currently registered) PLEASE CHECK ONLY ONE BOX BELOW: This volunteer fire company is registering a fire vehicle, as defined in §115-a of the Vehicle and Traffic Law, which is owned or controlled by a fire company, as defined in §3 of the Volunteer Firefighters’ Benefit Law. This volunteer ambulance company is registering an Emergency Ambulance Service Vehicle (EASV), as defined in §115-c of the Vehicle & Traffic Law, which is owned or controlled by an ambulance company, as defined in §3 of the Volunteer Ambulance Workers’ Benefit Law. CERTIFICATION I certify that the above-described vehicle(s) is (are) owned or controlled by the volunteer organization to which this application for registration applies, and that the information contained herein is true and accurate. I do so in my capacity as an officer who has been granted the authority to act on behalf of the above-named organization. I understand and agree that if, in the future, the above-described vehicle or my organization no longer meets the qualifications listed (cited in the check boxes above), it is the above-mentioned organization’s responsibility to surrender the registration items to the NYS DMV. Failure to surrender the registration items may result in the suspension of the registration. I understand that knowingly making a false statement on an application submitted to the Commissioner of Motor Vehicles is a misdemeanor under Vehicle and Traffic Law, a misdemeanor or felony under New York State Penal Law, and may result in criminal prosecution in addition to revocation or suspension of the registration pursuant to regulations promulgated by the Commissioner of Motor Vehicles. Signature ± __________________________________________________________ Date: __________________________ (Sign Your Name in Full) Print Your Name: ______________________________________________ Title: ____________________________________ Address: ______________________________________________________________________________________________ OFFICE USE ONLY City: _______________________________________________________________ Zip Code: __________________________ Authorization Code ______________________ Code from List Code from IOCU FS Insurance Card Presented Insurance Company Code_________________ Insurance Effective Date __________________ DMV Supervisor Approval: _________________________________________________ Date: ___________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com