Account Maintenance Form - Nys Department Of Transportation Page 2
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VERSION (04/14)
INSTRU TIONS
C
A completed Account Maintenance Form must be submitted in order to establish an account with the
OS/OW Program. This form allows for additional information not provided on an application itself (DBA,
multiple contact numbers, etc.). For existing accounts, the Account Maintenance Form must be
s
ubmitted to make changes to account-level information.
To submit this form using e-mail, save the completed form to your computer. Open your e-mail and
a
ttach the completed form and e-mail to:
Permits@dot.ny.gov
To submit this form using a fax machine; please include a cover letter addressed to "Processing" and
fax the completed form to 518-457-1036.
Customer No.
Please check the appropriate box; New Customer, Account Update or Account Closure when
submitting this form.
New Customer:
This is the first time applying for a permit. All applicable fields must be completed.
Account Update: Must provide your existing Customer number in space provided
You are an existing customer and are changing any of the following information:
•
Company Name
•
Doing Business As name (DBA)
•
USDOT number
•
Federal Identification Number (FEIN)
•
Physical Address or any parts there of
•
Mailing Address or any parts there of
•
Contact Person information
Account Closure:
If you are an existing customer and you wish to close an existing permit account you are
acknowledging that the identified account is no longer required and that submission of this request
forfeits all associated permit rights to that account.
Please indicate Reason for closure of account; sale, transfer of business, closing business etc.
If monies remain on any closed account they will be refunded to the mailing address shown in the
system at time account is closed.
For multiple account closures you must submit one signed and dated Account Maintenance Form per
account.
Permit Service Submittal Acknowledgement:
By checking YES, you are acknowledging that you agree to allow Permit Service Companies to act as
an Authorized Representative of your company and apply for and receive permits on your or your
companies’ behalf.
Affirmation:
The Affirmation portion of this form must be signed, written or typed and dated in order for this form to
be considered valid.
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