Form Vs-117 - Application For A Motor Vehicle Body Damage Estimator License Page 2
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1
2PRESENT EMPLOYER
FACILITY NUMBER
BUSINESS TELEPHONE NUMBER
(if applicable)
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16ç
17ç
(
)
BUSINESS ADDRESS
CITY
STATE
ZIP CODE
(NUMBER AND STREET)
19ç
20ç
(FOR ORIGINAL APPLICATIONS ONLY)
Have you ever been convicted of any felony or misdemeanor?
o
o
Yes
No
If “YES”, give details below:
(Applicants will not necessarily be rejected because of a conviction record. Each record will be reviewed on an individual basis.)
Date of Violation
What is the Violation?
Date of Conviction
Disposition & Fine
Court Location
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(FOR ORIGINAL APPLICATIONS ONLY) List all motor vehicle body damage estimator experience:
Dates (From - To)
Employer’s Name and Address
Type of Work
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(FOR ORIGINAL APPLICATIONS ONLY) List any trade school, vocational school, or other motor vehicle repair courses taken.
A copy of your diploma must be provided with this application if you have less than one year of work experience.
Dates of Attendance
School Name and Address
Type of Course
Type of Degree
Section 398(d) of the Vehicle & Traffic Law authorizes the licensing of motor vehicle body damage estimators. Anyone who has such a license
agrees to comply with the rules and regulations promulgated by the Commissioner of Motor Vehicles. Failure to comply with these rules and
regulations may result in the revocation of this license.
Notify this office of any change in your address.
FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW.
NAME
__________________________________________________________
(PLEASE PRINT)
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SIGNATURE __________________________________________
Date_________________
(Sign Name in Full - DO NOT PRINT - No Nicknames)
dmv.ny.gov
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