Personal History Form - New York State Dmv Page 2

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Social Security #: ______________________________
THIS FORM SHOULD BE SENT TO THE DEPARTMENT OF MOTOR VEHICLES
WITH THE APPLICATION PACKAGE.
CHECK ONE
Yes
No
8. Have you ever had a Private Service Bureau License, Driving School License, or Instructor’s Certificate denied, cancelled,
o
o
suspended or revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o
o
9. Within the past 12 months, have you been paid for giving driver training instruction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o
o
10. Within the past 12 months, have you been an instructor for a Point Insurance Reduction Program? . . . . . . . . . . . . . . . . . . . . . .
o
o
11. Within the past 12 months, have you been employed by a Private Service Bureau? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Have you ever been an officer, director, employee, stockholder, partner or owner in a corporation, or a partner in a business,
which has had a driving school license, or Private Service Bureau license revoked or suspended by the Department of Motor
o
o
Vehicles? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Use this space to explain any questions answered “Yes”. Please include the number of the question you are explaining. Attach additional pages,
if necessary and print your name on each attached page.
ATTACH
PHOTO
Photograph must have been
taken within past 30 days and
should be 1 7/8” wide by 2”
long, and must be a true
likeness showing only the
shoulders, neck and uncovered
head.
To knowingly make a false statement or to conceal a material fact on this form is a criminal offense, and may result in
the revocation of your Driving School License and/or Private Service Bureau License and/or Instructor Certificate.
I affirm under penalty of perjury that I have read this form and know the contents, and that all answers and statements are true. False
statements are punishable under Section 210.45 of the Penal Code.
ç
Name (Please print)
_____________________________________________________________
ç
Applicant’s Signature
____________________________________________________________ Date ______________________________
Sworn to before me this ____________ Day of ________________________________ in the Year of _________.
Notary Public Number and Signature
If there is any change regarding any information on this form, it must be reported in writing within ten days to the
Driving school at:
Department of Motor Vehicles, Bureau of Driver Training Programs, 6 Empire State Plaza, Room 412, Albany NY 12228.
Private Service Bureau Unit at:
Private Service Bureau Unit, Registration Services, 6 Empire State Plaza, Room 322P, Albany, NY 12228.
dmv.ny.gov
PAGE 2 OF 2
MV-521.1 (9/15)
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