MV-278 Form – Fill Out and Use This PDF

MV-278/PRE-LICENSING COURSE COMPLETION CERTIFICATE ORDER FORM

FOR COMMERCIAL PRE-LICENSING COURSE PROVIDERS

dmv.ny.gov

PLEASEPRINT CLEARLYINBLUE INK.

PROVIDER INFORMATION

Business Name

MailingAddress (Street and Number)		Room Number
City	State	Zip Code

*The requester’s name and signature must be listed on theAuthorized Signature List (MV-278.6) for this school.

ORDER INFORMATION

Each book contains 50 certificates (MV-278). Specify the number of books you are ordering and the payment amount included:

________ Books of Certificates @ $50 each = $ 0

Payment must be made in full (no partial payment will be accepted) and included with this form.

Payment must be made by check or money order payable to the “Commissioner of Motor Vehicles”.

DO NOT SEND CASH.

CERTIFICATION

IunderstandthatIamrequiredtosubmitcompletedrosterstomylocalTestingandInvestigationUnit.Icertifythat:

·IhavesubmittedcompletedrosterstotheTestingandInvestigationUnitidentifiedbelow;

·sincemylastorder,IhavesubmittedtothatUnitcompletedrosterswiththedaterangeprovidedbelow;

·sincemylastorder,myschoolissuedthenumberofPre-licensingCourseCompletionCertificates(MV-278)providedbelow;and,

·IamauthorizedtoorderPre-licensingCourseCompletionCertificates.

IcertifythattheinformationIhaveprovidedonthisformistrueandcompletetothebestofmyknowledge.

WARNING: Intentionally making a false statement or providing false or misleading information in connection with this applicationisacriminaloffensethatmaysubjectyoutocriminalprosecutionundertheLaw.

Testing and Investigation Unit: _______________________________________________________________________

Number of Certificates Issued: ___________ Date Range: ___________________________________________

*Authorized Signature (in blue ink): X _________________________________________________________________

INSTRUCTIONS

1.Complete this order form. Allow 2 – 3 weeks for processing and delivery time.

2.Enclose a check or money order for the appropriate fee, payable to the “Commissioner of Motor Vehicles”.

•DO NOT SEND CASH.

•A$35 fee will be charged for each dishonored check.

•The account holder’s name must be preprinted on the check. “Starter checks” will not be accepted.

3.Send the completed order form and payment to:

NYS DEPARTMENT OF MOTOR VEHICLES PRE-LICENSING PROGRAM

207 GENESEE STREET, SUITE 6 UTICA, NY13501

4.Return class rosters for the MV-278 certificates issued by your organization since your last order to your localTesting and Investigation Unit. Future order quantities will be evaluated based on completed and submitted rosters (see “Certification”onorderform). Ifthatquantityisdifferentthanthatrecordedinyourinitialnotification,DMVwillcontactyou.

5.If you have any questions, or would like additional information, contact your local DMVcall center at 1-518-486-9786 or 1-800-698-2931.

ORDERS WILL BE REJECTED IFANY OF THE FOLLOWINGAPPLY: