STATEMENT OF OWNERSHIP AND/OR
PERMISSION TO USE PLACE OF BUSINESS
(Please Print)
YOUR BUSINESS
Business
Phone No. (Include Area Code)
Name (DBA)
(
)
Business
Address
City
State
Zip Code
OWNER OF PROPERTY
(This section must be filled out)
Name of Property
Phone No. (Include Area Code)
Owner
(
)
Owner Mailing
Address
City
State
Zip Code
Number of Years or Months Owned? Is this property zoned for business use?
Do you own your business property?
o
o
o
o
Yes
No
Yes
No
NOTE:
Whether you own or are leasing your business property, it is your responsibility to be in compliance with all state and
local laws and regulations, while being considered for registration and while conducting your business.
LEASING INFORMATION
(If you are leasing, please complete the following section)
Print the name
Phone No. (Include Area Code)
the lease is in
(
)
Must have at least six-month lease
Business
Address
/
/
Expiration Date
SUB-LEASING INFORMATION
(If you are sub-leasing, please complete the following section)
Print the name
the sub-lease is in
Business
Must have at least six-month lease
Address
/
/
Expiration Date
PLEASE ATTACH ADDITIONAL PAGES, IF NEEDED.
If any of the leases will expire in the next six months, you must provide a letter from the owner or lessor stating the intention to
renew that lease. If you do not provide this information with your application, the application will be denied.
CERTIFICATION
(To be completed by owner/partner/officer)
False statements on this application are punishable by law and may result in denial, suspension or revocation of your
business certificate(s), as authorized by Regulations of the Commissioner of Motor Vehicles. I certify that I am the
owner, partner, officer or agent of the business named on this application, and that the information in this application is true.
Full Last Name of Applicant (Please Print)
First
M.I.
Date of Birth (Month/Day/Year)
/
/
Residence Street Address (Include Street Number and Name, Rural Delivery, Box and/or Apartment Number)
City
State
Zip Code
Signature of Applicant
x
(Sign name in Full)
Title of
Date
Applicant
VS-19 (4/18)
dmv.ny.gov
STATEMENT OF OWNERSHIP AND/OR
PERMISSION TO USE PLACE OF BUSINESS
(Please Print)
YOUR BUSINESS
Business
Phone No. (Include Area Code)
Name (DBA)
(
)
Business
Address
City
State
Zip Code
OWNER OF PROPERTY
(This section must be filled out)
Name of Property
Phone No. (Include Area Code)
Owner
(
)
Owner Mailing
Address
City
State
Zip Code
Number of Years or Months Owned? Is this property zoned for business use?
Do you own your business property?
o
o
o
o
Yes
No
Yes
No
NOTE:
Whether you own or are leasing your business property, it is your responsibility to be in compliance with all state and
local laws and regulations, while being considered for registration and while conducting your business.
LEASING INFORMATION
(If you are leasing, please complete the following section)
Print the name
Phone No. (Include Area Code)
the lease is in
(
)
Must have at least six-month lease
Business
Address
/
/
Expiration Date
SUB-LEASING INFORMATION
(If you are sub-leasing, please complete the following section)
Print the name
the sub-lease is in
Business
Must have at least six-month lease
Address
/
/
Expiration Date
PLEASE ATTACH ADDITIONAL PAGES, IF NEEDED.
If any of the leases will expire in the next six months, you must provide a letter from the owner or lessor stating the intention to
renew that lease. If you do not provide this information with your application, the application will be denied.
CERTIFICATION
(To be completed by owner/partner/officer)
False statements on this application are punishable by law and may result in denial, suspension or revocation of your
business certificate(s), as authorized by Regulations of the Commissioner of Motor Vehicles. I certify that I am the
owner, partner, officer or agent of the business named on this application, and that the information in this application is true.
Full Last Name of Applicant (Please Print)
First
M.I.
Date of Birth (Month/Day/Year)
/
/
Residence Street Address (Include Street Number and Name, Rural Delivery, Box and/or Apartment Number)
City
State
Zip Code
Signature of Applicant
x
(Sign name in Full)
Title of
Date
Applicant
VS-19 (4/18)
dmv.ny.gov
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