Form Vs-95 - Public Emissions Inspection Station Buy/sell Agreement Page 2
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1
2Print Name
Title(s)
Date of Birth
Signature
/
/
Notary Stamp Below
Sworn to and signed before me this ________________day,
in the year of _________________.
_______________________________________________
(Notary Public)
Print Name
Title(s)
Date of Birth
Signature
/
/
Notary Stamp Below
Sworn to and signed before me this ________________day,
in the year of _________________.
_______________________________________________
(Notary Public)
Print Name
Title(s)
Date of Birth
Signature
/
/
Notary Stamp Below
Sworn to and signed before me this ________________day,
in the year of _________________.
_______________________________________________
(Notary Public)
Print Name
Title(s)
Date of Birth
Signature
/
/
Notary Stamp Below
Sworn to and signed before me this ________________day,
in the year of _________________.
_______________________________________________
(Notary Public)
*This form must be notarized within 90 days prior to receipt by DMV.
Purchaser Information:
Name: ________________________________________ Daytime Contact Phone: (_____) _______-______________
Contact Address: _________________________________________________________________________________
_________________________________________________________________________________
Facility Number (if applicable): _______________________
Computerized Vehicle Inspection System (CVIS):
In addition to transferring the facility licenses and certificates, every official public emissions station needs to have a CVIS.
The current provider of the CVIS in New York State is Opus Inspection. Please contact them regarding transferring equipment
or an original equipment purchase at (866) 623-8378 or at
VS-95 (5/15)
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