Personal History Form - New York State Dmv

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PERSONAL HISTORY
Please
Check
OR
One:
Last Name
First
M.I.
Title
Social Security Number
Home Mailing Address (Street & Number)
City
State
Zip Code
Apt. #
Home Phone Number
(
)
Driver License I.D. Number
Place of Birth
License Expiration Date (Month/Day/Year)
Date of Birth (Month/Day/Year)
o
o
/
/
/
/
Male
Female
Name of Business
Business Phone Number
(
)
Address of Business (Street & Number)
City
State
Zip Code
Note: Section 5 of the NYS Tax Law requires the Department of Motor Vehicles to provide Social Security numbers to the NYS Department
of Taxation and Finance upon request.
LIST EMPLOYMENT EXPERIENCE FOR LAST 5 YEARS. List the most recent first. (Attach additional sheets, if necessary.)
Name and Address of Business
Job Description/Title
Dates Employed (month/year)
Reason for Leaving
From
To
Name and Address of Business
Job Description/Title
Dates Employed (month/year)
Reason for Leaving
From
To
Name and Address of Business
Job Description/Title
Dates Employed (month/year)
Reason for Leaving
From
To
Name and Address of Business
Job Description/Title
Dates Employed (month/year)
Reason for Leaving
From
To
Name and Address of Business
Job Description/Title
Dates Employed (month/year)
Reason for Leaving
From
To
ANSWER ALL QUESTIONS
CHECK ONE
For every question answered “yes”, you must provide a complete explanation on page 2 of this form.
Yes
No
o o
1.
Have you ever been known by any name other than the one shown on this personal history form?. . . . . . . . . . . . . . . . . . . . . . .
2.
Have you ever been convicted of a felony, or of any crime involving violence, dishonesty, deceit, indecency, degeneracy or
o o
moral turpitude? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
Have you ever been convicted of perjury or of making any false statements relating to any part of the New York State
o o
Vehicle and Traffic Law? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o o
4.
Are you now involved with any charges or court proceedings relating to the matter stated in question 3? . . . . . . . . . . . . . . . . .
o o
5.
Have you ever been convicted of any traffic violations (not parking violations)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o o
6.
Has your driver license ever been denied, cancelled, suspended or revoked in New York or any state? . . . . . . . . . . . . . . . . . . .
o o
7. a. Have you been affiliated with, or employed by, any other driving school(s) or Private Service Bureaus? . . . . . . . . . . . . . . . . . .
b. If “yes”, list the name(s) of the schools or Private Service Bureaus:
PAGE 1 OF 2
Continue on Page 2
MV-521.1 (9/15)

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