FEE SCHEDULE
OFFICE USE ONLY
APPLICATION FOR A LICENSE
TO OPERATE A
Original Application . . . . . . $25.00
Application No.
Date
Branch Office(per branch). $ 1.50
PRIVATE SERVICE BUREAU OR
Lic. #
Date
OPEN A BRANCH OFFICE
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NSTRUCTIONS:
Print or type the information in this application.
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Refer to the Private Service Bureau page of the NYS DMV website ( )
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for information about the documents that must accompany this application.
Date of Application (Mo./Day/Yr.)
Name of Private Service Bureau
Federal Employer ID Number*
Mailing Address of Private Service Bureau (Street & No.)
City
State
Zip Code
If you also plan to operate a branch office, provide the branch office address:
Type of Business (check one of the following):
Telephone
Fax #
o
o
o
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(
)
(
)
Sole Proprietor
Partnership
Corporation
Association
List names, addresses and social security numbers of all owners, partners, corporation officers, stockholders and managers,
(continue on additional sheet, if necessary).
A photocopy of the NYS Driver License or Non-Driver ID card for all owners, partners, corporate officers, managers and major stockholders, is required.
Name
Social Security Number*
Address
Owners
Partners
Corp. Officers
Managers
Major Stockholders
*As required by Section 5 of the NYS Tax Law, the social security number of individuals and the Federal Employer ID Number of businesses regulated by
the Department of Motor Vehicles must be given to the New York State Department of Tax and Finance.
ANSWER ALL QUESTIONS IN THE FOLLOWING SECTION:
CHECK ONE
Yes No
1. Have any of the owners, partners, corporation officers, managers or major stockholders ever operated a Private Service Bureau before?
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(If Yes, complete “Explanations” section below by giving dates of operation and reason for discontinuance if not still in operation) . . . . . . . . . .
2. Where is your Private Service Bureau operated from? (for example, office space, residence, etc.)
________________________________
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3. Is the Private Service Bureau conducted in conjunction with any other business? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Yes, what kind of business?
_________________________________________________________________________________________
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4. Is your Private Service Bureau within 1500 feet from the nearest state or county office where driver licenses or vehicle registrations are issued? . . .
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5. Do you share office space or desk room with any other business? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Yes, what kind of business?
____________________________________________________________________________
EXPLANATIONS
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MV-372 (10/15)
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