Form Mv-409 - Application For Certification Of Official Vehicle Safety Inspector

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MV-409 (9-10)

Application for

Certification of

Official Vehicle

Bureau of Motor Vehicles

Vehicle Inspection Division

Safety Inspector

P.O. Box 68697

Harrisburg, PA 17106-8697

For Department Use Only

PRINT OR TYPE ALL INFORMATION - MUST BE SUBMITTED TO AN APPROVED EDUCATIONAL FACILITY

Applicant must be 18 years of age and have a valid operator’s license for each class of vehicle he/she intends to inspect. Applicant must also complete a

lecture course at an approved educational facility, pass a written test and satisfactorily perform a complete inspection of a vehicle. Upon successful completion

of these courses, you will receive your certified safety inspection certification card in approximately six to eight weeks from your ending class date. The school

has 35 days from the class ending date to submit the paperwork for processing. You may not begin inspecting until you receive your certification card.

A APPLICANT INFORMATION

LAST NAME

FIRST NAME

MIDDLE NAME

BIRTH DATE

STATE

SEX

DRIVER’S LICENSE NUMBER

r M

r F

COUNTY

STREET ADDRESS

CITY

STATE

ZIP CODE

WORK TELEPHONE NUMBER

HOME TELEPHONE NUMBER

Do you currently hold a valid out-of-state driver’s license? (If yes, attach a copy.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

*Contact PennDOT’s Vehicle Inspection Division at 717-787-2895 to establish an out-of-state mechanic record prior to completion of this class.

Restrictions (If any, listed on applicant’s driver’s license)?______________________________________________________________

Do you currently hold a valid Pennsylvania driver’s license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

Have you held a Pennsylvania driver’s license in the past? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

Do you currently hold a Pennsylvania probationary driver’s license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

If yes, how long have you had this license? ____________________ years.

Do you currently hold a Pennsylvania occupational limited driver’s license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

Are you currently required to use an ignition interlock device? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

What class(es) is/are listed on your driver’s license? ___________________________________________________

Do you currently hold a valid CDL license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

Do you read, write and understand the English language? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r Yes

r No

What type of vehicles do you intend to inspect?

r Passenger cars/trucks 17,000 lbs. or less/trailers 10,000 lbs. or less

r Motorcycles

r Buses/trucks over 17,000 lbs./trailers over 10,000 lbs.

I hereby certify, under penalty of law, that the above information is correct to the best of my knowledge. WARNING: Any false statement on this applica-

tion could subject the applicant to prosecution under Section 4903 of the “Crimes Code,” and punishment upon conviction of a fine not more than $5,000

and/or imprisonment for not more than two years.

APPLICANT’S SIGNATURE IN INK

B INSTRUCTOR/TESTING INFORMATION

SCHOOL NAME

SCHOOL VEMIS NO. (4 DIGITS)

INSTRUCTION DATES (mm/dd/yy)

INSTRUCTOR’S NUMBER

FROM:

TO:

WRITTEN TEST SCORE

Instructor’s No.’s

FILL IN BELOW