Facility Application Form – Fill Out and Use This PDF

PART 1 Check business type(s) that you are applying for:

The information in parentheses indicates the section of Part 7 that must be completed for each type selected.

*§415(7)(f) of the NYS Vehicle and Traffic Law prohibits the issuance of a dealer registration to franchisors as defined in Vehicle and Traffic Law §462(8). If you are such a franchisor of passenger cars, SUVs, light trucks, pickup trucks, vans, minivansorsuburbans,withagrossvehicleweightratingoftenthousandpoundsorless, DONOTsubmitthisform.

** Snowmobile dealers do not use this form; if you are a snowmobile dealer, please use form RV-253.

PART 2 Check type of ownership (one ownership type per application) and include paperwork described below:

oIndividual (doing business in your legal name)

ØProof of business name not required.

oIndividual w/ assumed name (“doing business as” or DBAname)

ØEnclose a copy of the business certificate obtained from your County Clerk’s office.

oPartnership w/ assumed name (“doing business as” or DBAname)

ØEnclose a copy of the partnership papers obtained from your County Clerk’s office. The partnership papers must contain all partners’ names and the DBAname.

oCorporation (Inc., Corp., Ltd.)

ØEnclose a copy of the filing receipt issued from the NYS Department of State: (518) 473-2492 or www.dos.ny.gov

oCorporation w/ assumed name (“doing business as” or DBAname)

ØPrint corporation name below and enclose a copy of the filing receipt with the assumed name issued from the NYS Department of State: (518) 473-2492 or www.dos.ny.gov

Corporation Name____________________________________________________________________________

oLimited Liability Company (LLC)

ØEnclose a copy of the filing receipt issued from the NYS Department of State: (518) 473-2492 or www.dos.ny.gov

oEducational Facility (School, BOCES)

ØPrint Superintendent’s name below. No documents required for proof of business name.

Superintendent (Name and Phone No.) ___________________________________________________________

oGovernment Agency (State, County, City)

ØPrint Government Official’s name below. No documents required for proof of business name.

Government Official (Name and Phone No.) ______________________________________________________

If you need assistance, call the Office of Vehicle Safety Application Unit at 518-474-0919 between 7:30 a.m. and 4:00p.m.

Forms are available at www.dmv.ny.gov

VS-1 (6/12)

*VS-1*

PAGE 1 OF 6

PART 3 Print, name and location of business, and business e-mail address, below:

PART 4 Ownership information (complete the section that applies):

A.INDIVIDUAL OWNERSHIP: Attach a copy of the owner’s Driver License. (If the owner does not have a Driver License, attach a copy of one of the

following: Non-Driver ID, passport or resident alien card.)

Last Name	First	MI	Date of Birth (Month/Day/Year)

B.PARTNERSHIP: Complete one section for each partner; if more than three, attach additional pages.Attach a copy of each partner’s Driver License. (If a

partner does not have a Driver License, attach a copy of one of the following: Non-Driver ID, passport or resident alien card.)

	ResidenceAddress (Include Number and Street)	City		State	ZIP			Residence Phone No. (Area Code)
								(	)
	Please Sign Name In Full			Driver Identification Number			Social Security Number
	ç
2.	Last Name		First			MI			Date of Birth (Month/Day/Year)
	ResidenceAddress (Include Number and Street)	City		State	ZIP			Residence Phone No. (Area Code)
								(	)
	Please Sign Name In Full			Driver Identification Number			Social Security Number
	ç
3.	Last Name		First			MI			Date of Birth (Month/Day/Year)
	ResidenceAddress (Include Number and Street)	City		State	ZIP			Residence Phone No. (Area Code)
								(	)
	Please Sign Name In Full			Driver Identification Number			Social Security Number
	ç

C. CORPORATION or LIMITED LIABILITY COMPANY: For Inc., Corp., and Ltd., list corporate officers (President, Secretary and Treasurer are required). List stockholders and percentage of stock (not required for publicly-traded companies). For LLC, list all managing members. Attach additional pages if needed.Attach a copy of each listed person’s Driver License. (If any listed person does not have a Driver License, attach a copy of one of the following:

Non-Driver ID, passport or resident alien card.)

1. Last Name	First	MI	Date of Birth (Month/Day/Year)

ResidenceAddress (Include Number and Street)	City		State	ZIP			Residence Phone No. (Area Code)
							(	)
Please Sign Name In Full			Driver Identification Number			Social Security Number
ç
2. Last Name		First			MI			Date of Birth (Month/Day/Year)

ResidenceAddress (Include Number and Street)	City		State	ZIP			Residence Phone No. (Area Code)
							(	)
Please Sign Name In Full			Driver Identification Number			Social Security Number
ç
3. Last Name		First			MI			Date of Birth (Month/Day/Year)

ResidenceAddress (Include Number and Street)	City	State	ZIP		Residence Phone No. (Area Code)
					(	)
Please Sign Name In Full		Driver Identification Number		Social Security Number

ç

VS-1 (6/12)

PAGE 2 OF 6

PART 5 Complete all sections:

A. Have you or any person named in this application ever had a financial interest in a DMV-regulated business that had its license,

registrationorcertificationdenied,suspendedorrevokedinNewYorkState?Thisincludesaninterestasowner,partner,corporate

officer or stockholder holding more than ten percent of the stock, and includes matters now on appeal. o NO o YES

If “YES”: Specify name and address of the person(s), business type, date and action taken against the business.

B. Are you, or is anyone named in this application, scheduled for a hearing that may result in the suspension, revocation

or denial of a DMV Vehicle Safety issued business license, registration or certification? o NO o YES

If “YES”: Specify name and address of the person(s), business type, date and reason for hearing.

C. Have you or any person named in this applicationbeen convicted of, or forfeited bail for, any misdemeanor or felony at any time? o NO o YES

If “YES”: Name _________________________________________________________ Date of Birth ______________

Conviction Date __________________ Penalty _____________ Court ________________________________________

Explain nature of offense (Further explanation may be attached.) ________________________________________________

_________________________________________________________________________________________________

D. Does anyone else have a financial interest in your business that is not disclosed on this application? o No o Yes

If “YES”: Name ________________________________________________________________________________

E.All applicants must provide Sales Tax Number here _________________________________ (except Inspection Stations, Yacht Brokers and Transporters). You must attach a photocopy of the Certificate ofAuthority (DTF-17A) from the NYS Department of Taxation and Finance: www.tax.ny.gov or 1-800-698-2909

F.Do you have any employees? o NO o YES

If “YES”: provide your Federal Employer Identification Number______________________, and attach a copy of proof of

Worker’sCompensationandDisabilityInsurancecoveragefromtheNYSInsuranceFund: ww3.nysif.com or (212)312-9000

G. Have you ever held a business license, registration or certification for any of the business types listed below? oNO o YES If “YES”: Check the type(s) below and provide all current and previous facility numbers.Attach additional page, if needed.

o Retail Motor Vehicle Dealer, New	o Dismantler	o ATV Dealer	o Inspection Station	o Scrap Collector
o Retail Motor Vehicle Dealer, Other	o Transporter	o Salvage Pool	o Qualified Dealer	o Scrap Processor
o Wholesale Motor Vehicle Dealer	o Boat Dealer	o Repair Shop	o Mobile Car Crusher
o Itinerant Vehicle Collector	o Yacht Broker	o Repair Shop disposing of major component scrap

Current facility numbers __________________________ __________________________ _________________________

Previous facility numbers _________________________ __________________________ _________________________

A. All applicants must complete this section.

Name of Property Owner				Phone No. (Area Code)
				(	)
Owner MailingAddress (Include Number and Street)
City			State		ZIP
Number of Years or Months Owned?		Is this property zoned for the business type(s) you are applying for?	oYES oNO

PLEASE NOTE: Whether you own or are leasing your business property, it is your responsibility to be in compliance with all state and local laws and regulations, while being considered for registration and while conducting your business. If any of the leases will expire in the next six months, you must provide a letter from the owner or lessor stating the intention to renew that lease. If you do not provide this information with your application, the application will be denied.

B. If you are leasing or subleasing, complete this section.

Print the Name the Lease Is In (Lessee Name)					Phone No. (Area Code)
					(	)
BusinessAddress	City	State	ZIP	Must Have at Least Six-Month Lease -
				Expiration Date		/	/

C. If you are subleasing, complete this section.

Print the Name the Sublease Is In (Sublessee Name)					Phone No. (Area Code)
					(	)
BusinessAddress	City	State	ZIP	Must Have at Least Six-Month Lease -
				Expiration Date		/	/

VS-1 (6/12)

PAGE 3 OF 6

PART 7 Complete all sections that apply to the business type(s) checked in Part 1:

Section A REPAIR SHOP REGISTRATION – If completing this section, answer all questions and see VS-145, Repair Shop Requirements.

(Authority: Vehicle and Traffic Law Section 398; Commissioner’s Regulations Part 82)

FEES Application Fee: $10 Two-Year Registration Fee: $150 Total (Application Fee plus Two-Year Registration Fee): $160

If applying for more than one business type, only pay highest application fee plus two-year registration/license fee for each business type.

1.	Check one Repair Shop type: o Repair Shop		o Body Repair Shop (over 75% of work is body repair)
	o Drive-inAppraisal		o Mobile Repair Shop (repair shop on wheels)
2.	Does your shop service motor vehicle air conditioning systems? oNo oYes			If “Yes”, you must send, with your
	application, a Manufacturer’s Certificate or an invoice as proof of purchase of motor vehicle refrigerant recycling equipment,
	as required by Section 398-c of the New York State Vehicle and Traffic Law. For information about approved equipment:
	www.epa.gov/ozone/title6/609/technicians/appequip.html
3.	Repair Shop disposing of vehicular scrap.	oNo oYes	If “Yes”, you are certifying as a Repair Shop disposing of major
	component parts (including transmissions, engines, noses, frames or bodies). Identify the Scrap Processors with which you will
	do business.Attach an additional page if you need more room to list these businesses.
	Name	Address		Facility Number
	_________________________________	____________________________________________ ________________

4.If you are applying for a Repair Shop or Body Repair Shop registration, you must enclose a certificate of occupancy, a local license, or a letter from your local authority stating that you may operate a Motor Vehicle Repair Shop. The letter from your local authority must be on its letterhead, be dated (not more than ten years old), and contain the following: the full name and address of your business, type of business, a statement that you may operate a Motor Vehicle Repair Shop at the location identified on your application, and the printed name and title of the official preparing the letter. OR Provideproofthat aregisteredrepairshopisorwasoperatingatthatlocation.Providethepreviousfacilitynumber,andthebusinessname,ifknown:

Facility Number __________________________Business Name ______________________________________________

Section B INSPECTION STATION LICENSE – If completing this section, answer all questions and see VS-143,

Inspection Station Requirements.

(Authority: Vehicle and Traffic Law Sections 215, 302, 303; Commissioner’s Regulations Part 79)

FEES Application Fee: $25 Two-Year License Fee: $100 Total (Application Fee plus Two-Year License Fee): $125

If applying for more than one business type, only pay highest application fee plus two-year registration/license fee for each business type.

1.Check the type of station license you are requesting (only one):

oPublic Inspection Station – Inspects vehicles for general public and must have a Repair Shop at the same location. oDealer Inspection Station – Must have a dealer registration. Dealer business name and Inspection Station name must

be the same. Inspects only vehicles owned by the Dealership and its employees.

oFleet Inspection Station – Business must have more than 25 vehicles registered in its name, and perform inspections only on its own vehicles and vehicles owned by employees of the firm.

If you checked “Fleet Inspection Station”, how many vehicles are registered in the business name?____________________

2.Check the inspection group(s) for vehicles you intend to inspect, and for which you have the necessary space and equipment:

Group 1 oa & b

o b only

a.Allpassengervehicles,suburbans,andtrucksuptoandincluding18,000poundsMGW.Allpublicstationsmusthavea NYVIP emissions system. For information on purchasing inspection equipment, call SGS Testcom at 1-866-469-8477.

b.Trailers up to and including 18,000 pounds MGW

Group 2 oa & b

o a only o b only

a.All motor vehicles over 18,000 pounds MGW

All motor vehicles that have an MGW over 10,000 pounds and under 18,001 pounds, when requested by the registrant

All motor vehicles with a seating capacity of more than fourteen passengers

All trailers that have an MGW over 18,001 pounds, and those trailers that have an MGW over 10,000 pounds and under 18,001 pounds, when requested by the registrant

b. All semi-trailers

Group 3 oMotorcycles

Group DL o Diesel Emissions testing

VS-1 (6/12)

SECTION B CONTINUED ON PAGE 5

PAGE 4 OF 6

SECTION B CONTINUED FROM PAGE 4

3.If you will perform Diesel Emissions Inspections, print the manufacturer’s name and the model number of the testing

equipment here: _______________________________________________________	___________________________
(Manufacturer’s Name)	(Model Number)

4.What is the length and width (in feet) of your enclosed inspection area? ____________ X____________= _____________

(Length) (Width) (TotalArea)

What is the height of your overhead door (in feet)? ____________________

(Overhead Door Height)

5.Give the name and certificate number of each of the Certified Inspectors at your facility.Attach an additional page if you need more room to list the inspectors. You must have at least one full-time inspector.

Name	Certificate Number	Expiration Date
______________________________________________________	______________________	__________________
______________________________________________________	______________________	__________________

SECTION C ALL DEALER REGISTRATIONS (MOTOR VEHICLE, BOAT, TRANSPORTER, AND ATV) –

If completing this section, see VS-141, Dealer Supply List and VS-142, Dealer/Transporter Requirements.

(Authority: Vehicle and Traffic Law Sections 415, 417, 2257, 2282; Commissioner’s Regulations Parts 78, 103, 104)

Dealer Type	Application Fee	2-year Registration Fee			Total (Application fee, plus 2-year Registration Fee)
All Motor Vehicle Dealers	$ 37.50	$	450.00	$	487.50
**Boat Dealers	** $ 10.00	$	50.00	$	60.00
Transporters	$ 37.50	$	450.00	$	487.50
ATV Dealers	None	$	50.00	$	50.00

If applying for more than one business type, only pay highest application fee plus two-year registration/license fee for each business type.

**Boat Dealer application fee is always required, plus the highest application fee for any other business type if applying for more than one.

1.Check business type(s) below:

oRetail Motor Vehicle Dealer, New (franchised passenger cars, SUVs, light trucks, etc.) – With one or more franchise agreements with one or more registered manufacturers to sell at retail a particular make of new motor vehicle. Youmustincludeacopyofeveryfranchiseagreementwithyourapplication.Number of dealer platesrequested_______.

oRetail Motor Vehicle Dealer, Other (motorcycles, trailers, used cars, RVs, heavy trucks, etc.) – Engaged in retail or retail with wholesale buying, selling or dealing in motor vehicles, motorcycles, limited use vehicles or trailers of more than 1,000 pounds unladen weight (other than mobile homes). Number of dealer plates requested_______.

oWholesale Motor Vehicle Dealer – Engaged in buying, selling or dealing in motor vehicles, motorcycles or trailers at wholesale ONLY (cannot sell retail). Number of transporter plates requested_______.

oBoat Dealer – Engaged in buying, selling or trading boats designed to have a motor, and that can be used to transport one or more people across water. Number of boat dealer demonstration numbers requested_______. Number of dealer plates requested_______.

oTransporter – Requiring the limited operation of motor vehicles, motorcycles, limited use vehicles or trailers for the purpose of delivery, repair or improvements. Include a statement with your application that explains, in detail, why you need transporter plates. Number of transporter plates requested_______.

oATV Dealer – engaged in buying, selling or tradingATVs.

2.All Motor Vehicle Dealers are required to have in place a surety bond, in the appropriate amount, as follows:

$50,000 – Retail Motor Vehicle Dealer, New (franchised passenger cars, SUVs, light trucks, etc.)

$25,000 – Retail or Wholesale Motor Vehicle Dealer (other than New) that sold more than 200 vehicles during the last calendar year.

$10,000 – Retail or Wholesale Motor Vehicle Dealer (other than New) that sold 200 or fewer vehicles during the last calendar year.

Form VS-3, Dealer Bond Under New York State Vehicle and Traffic Law Section 415(6-b), must be completed by the surety company. The original form, with the surety company’s seal, business name, address and signature of owner/partner/corporate officer/managing member, and power of attorney papers must be included with your application.

VS-1 (6/12)

PAGE 5 OF 6

SECTION D JUNK AND SALVAGE REGISTRATIONS – If completing this section answer all questions and see VS-144, Junk and Salvage Requirements.

(Authority: Vehicle and Traffic Law Section 415-a; Commissioner’s Regulations Part 81)

FEES

Application Fee: None

Two-Year Registration Fee $100

Total $100

If applying for more than one business type, only pay highest application fee plus two-year registration/license fee for each business type.

1.Check the business registration for which you are applying:

oItinerant Vehicle Collector – purchases non-operable vehicles/components and sells them to dismantlers or scrap processors.

oMobile Car Crusher – operates a transportable device used for crushing motor vehicles for scrap.

oVehicle Dismantler – purchases, dismantles and sells motor vehicles and trailers for parts and/or scrap.

oSalvage Pool – acts on behalf of a vehicle owner or insurance company in the sale of junk and salvage vehicles or major components.

2.If you are applying for a Vehicle Dismantler or Salvage Pool registration, you must enclose a certificate of occupancy, a local license, or a letter from your local authority stating that you may operate a Vehicle Dismantler or Salvage Pool business. The letter from your local authority must be on its letterhead, be dated (not more than ten years old), and contain the following: the full name and address of your business, type of business, a statement that you may operate a Vehicle Dismantler or Salvage Pool business at the location identified on your application, and the printed name and title of the official preparing the letter.

3.Vehicle Dismantler and Salvage Pool applicants doing business in Queens, Kings, Richmond, Bronx and New York counties must also include photocopies of valid New York City licenses for Secondhand Dealer General and Secondhand DealerAuto, issued by the NYC Department of ConsumerAffairs: www.nyc.gov , call 311 within NYC, or call

(212) 639-9675 from outside NYC.

4.For Dismantler only – You must have equipment to recover air conditioning refrigerant. You must send, with your application, a Manufacturer’s Certificate or an invoice as proof of purchase of motor vehicle refrigerant recycling equipment, as required by Section 415-a of the New York State Vehicle and Traffic Law. For information about approved equipment: www.epa.gov/ozone/title6/609/technicians/appequip.html.

SECTION E CERTIFIED YACHT BROKERS AND JUNK AND SALVAGE CERTIFIED BUSINESSES

(Authority: Vehicle and Traffic Law Sections 415-a, 2257-b; Commissioner’s Regulations Part 81)

FEES

Application Fee: None

Business Fee: None

1.Check the type(s) of business(es) for which you are requesting certification: oYacht Broker – acts as an agent for either the buyer or the seller of a boat.

oScrap Processor – purchases motor vehicles or parts for processing into metallic and non-metallic scrap.

oScrap Collector – collects and disposes of miscellaneous scrap and vehicular scrap to dismantlers or scrap processors. oJunkandSalvagebusinessesbasedoutofstatethatdobusinessinNewYorkState mustapplytotheCommissionerfor an identification number, which shall be issued provided that such person complies with the laws and regulations of the

jurisdiction in which he/she has his/her principal place of business or engages in such business.

The following out-of-state businesses, doing business in New York State, must obtain an NYS Identification Number:

Dismantlers, Itinerant Vehicle Collectors, Mobile Car Crushers, Salvage Pools, Yacht Brokers, Scrap Processors, Scrap Collectors, and Repair Shops disposing of major component parts to junk and salvage businesses in New York State.

PART 8 Certification (all applicants must complete this section):

FALSE STATEMENTS ON THIS APPLICATION ARE PUNISHABLE BY LAW AND MAY RESULT IN DENIAL, SUSPENSION, OR REVOCATION OF YOUR BUSINESS CERTIFICATE(S), AS AUTHORIZED BY REGULATIONS ESTABLISHED BY THE COMMISSIONER OF MOTOR VEHICLES. The person signing this application states that he or she is owner, partner, officer or managing member of the facility named on this application, is not a franchisor as referred to in Vehicle and Traffic Law §415(7)(f), and that all information provided in this application is true.

ResidenceAddress (Include Number and Street)

City

State

ZIP

Please check the Requirement Checklist. You must meet all requirements to be approved.

Have you completedALL SECTIONS that apply to your business? Have you signed the application?

Have you included your check (NO STARTER CHECKS) or money order for the application and registration/licensing fees?

Make Payable to: Commissioner of Motor Vehicles
	Return the completed application by mail to:	OR	Physical address for express mail:
	Bureau of Consumer and Facility Services		Vehicle Safety Services
	Application Unit		Application Unit
	PO Box 2700		6 Empire State Plaza, Room 220
VS-1 (6/12)	Albany NY 12220-0700	Phone: (518) 474-0919	Albany NY 12228-0001	PAGE 6 OF 6