Form Mv-372r - Application For Private Service Bureau License Renewal Page 2
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27. What services do you offer to your customers, and what fees do you charge for these services?
Service Provided
Fee Charged
$
$
$
$
$
$
REQUIREMENTS
As a condition for receiving a renewed Private Service Bureau license, the undersigned agree to all of the following requirements:
A.
To maintain adequate records, as required by the New York State Vehicle and Traffic Law and Commissioner’s Rules and Regulations, and to
permit the inspection of such records at reasonable times by an authorized representative of the Department. The Department of Motor Vehicles
considers “reasonable times” to be 9:00 A.M. to 5:00 P.M., Monday through Friday.
Any employees/runners/agents (paid or unpaid) who have been convicted of a felony or misdemeanor shall not be permitted to be employed by
B.
the PSB, unless the employer has conducted a review pursuant to article 23-A of the New York Correction Law and determined that the
employee is qualified.
To comply with all state laws and regulations, and all municipal ordinances and regulations relating to public health and public safety, for the
C.
business facility.
To comply with all provisions of the New York State Vehicle and Traffic Law, Commissioner’s Rules and Regulations, and Department
directives relating to a Private Service Bureau.
CERTIFICATION -
The Undersigned certify that they have read and understood the foregoing application, and possess sufficient knowledge of the
contents hereof to state that all information provided in this application is true and accurate. False statements are punishable by New York State
Penal Law. Each owner, partner, manager, business officer and major stockholder (20% or more) of the Private Service Bureau must sign in the
space provided below
.
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Signature
Title
Date (mm/dd/yyyy)
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Signature
Title
Date (mm/dd/yyyy)
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Signature
Title
Date (mm/dd/yyyy)
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Signature
Title
Date (mm/dd/yyyy)
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Signature
Title
Date (mm/dd/yyyy)
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Signature
Title
Date (mm/dd/yyyy)
Please return this completed, signed form with all required documentation and your non-refundable, two-year, $50.00 renewal fee to:
NYS Department of Motor Vehicles
Partnering Programs
6 Empire State Plaza, Room 322
reset/clear
Albany, NY 12228
dmv.ny.gov
MV-372R (4/17)
Page 2 of 2
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