Tow Truck Company - Renewal Roster Of Vehicles - Nyc Department Of Consumer Affairs Page 2

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Tow
DMV License
DCA
Vehicle
Action
DCA Staff
Truck
Plate Number
Medallion
Identification
Initials and
Number
Number (VIN)
Date
 Keep on Roster (current truck)
1
 Remove from Roster
 Add to Roster (new truck)
 Replace truck on Roster
Replaces Tow Truck #___.
 Keep on Roster (current truck)
2
 Remove from Roster
 Add to Roster (new truck)
 Replace truck on Roster
Replaces Tow Truck #___.
 Keep on Roster (current truck)
3
 Remove from Roster
 Add to Roster (new truck)
 Replace truck on Roster
Replaces Tow Truck #___.
 Keep on Roster (current truck)
4
 Remove from Roster
 Add to Roster (new truck)
 Replace truck on Roster
Replaces Tow Truck #___.
 Keep on Roster (current truck)
5
 Remove from Roster
 Add to Roster (new truck)
 Replace truck on Roster
Replaces Tow Truck #___.
 Keep on Roster (current truck)
6
 Remove from Roster
 Add to Roster (new truck)
 Replace truck on Roster
Replaces Tow Truck #___.
 Keep on Roster (current truck)
7
 Remove from Roster
 Add to Roster (new truck)
 Replace truck on Roster
Replaces Tow Truck #___.
By signing below I understand that falsification of any statement made herein is an offense punishable by a fine or
imprisonment or both.
__________________________________
__________________________________
Signature
Title/Position (if any)
__________________________________
__________________________________
Print Full Name
Date
Page 2 of 2
Updated 03/2014

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