Form Mv-109 - Certification For Vanpool Plates Page 2
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1
2CERTIFICATION FOR VANPOOL PLATES
have read and understand the “Eligibility Requirements” for vanpool plates printed on page 1 of this certification.
I
The following required information is provided below (use a separate sheet if you need more space):
- the vehicle identification number and the year, make and model of the vehicle
- the route and geographic areas in which this vehicle will be used
- the names of the regularly-travelled highways and arterials included in these routes
- the names, addresses, pick-up locations and work locations (or other destinations) for all regular passengers
- the employer’s name and address, if different than passenger’s work location
- the approximate one-way mileage
- the time the first passenger is picked up, the time of arrival at each workplace, the time of departure from each workplace,
and the time the last passenger is dropped off.
___________________________________
___________
____________________________
Vehicle Identification Number
Year
Make/Model
I certify that the vehicle identified above complies with all vanpool requirements as indicated, and that the information I have
provided is true to the best of my knowledge
.
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___________________________________________________________________
____________________________
Registrant’s signature
Date
If you have any questions, call DMV’s Custom Plates Unit at (518) 402-4838
PAGE 2 OF 2
dmv.ny.gov
MV-109 (8/17)
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