Form MV-109 - Information and Certification for Vanpool Plates - New York
CERTIFICATION FOR VANPOOL PLATES
I have read and understand the “Eligibility Requirements” for vanpool plates printed on page 1 of this certification.
The following required information is provided below (use a separate sheet if you need more space):
- the vehicle identification number and the year, make and model of the vehicle
- the route and geographic areas in which this vehicle will be used
- the names of the regularly-travelled highways and arterials included in these routes
- the names, addresses, pick-up locations and work locations (or other destinations) for all regular passengers
- the employer’s name and address, if different than passenger’s work location
- the approximate one-way mileage
- the time the first passenger is picked up, the time of arrival at each workplace, the time of departure from each workplace, and the time
the last passenger is dropped off.
I certify that the vehicle identified above complies with all vanpool requirements as indicated, and that the information I have provided is true
to the best of my knowledge.
ç___________________________________________________________________ ____________________________
___________________________________ ___________ ____________________________
MV-109 (9/15)
Registrant’s signature
www.dmv.ny.gov
Vehicle Identification Number Year Make/Model
Date
If you have any questions, call DMV’s Custom Plates Unit at (518) 474-6660 or (518) 474-7106.
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