Form Mv-278.8 Cds - Mv-278/pre-Licensing Course Completion Certificate Order Form For Commercial Pre-Licensing Course Providers
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2MV-278/PRE-LICENSING COURSE COMPLETION CERTIFICATE ORDER FORM
FOR COMMERCIAL PRE-LICENSING COURSE PROVIDERS
dmv.ny.gov
PLEASE PRINT CLEARLY IN BLUE INK.
PROVIDER INFORMATION
Business Name
Mailing Address (Street and Number)
Room Number
City
State
Zip Code
Authorized Signature (Required, in blue ink)
*
Print Name and Title
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Business Phone
E-Mail Address
*
The requester’s name and signature must be listed on the Authorized Signature List (MV-278.6) for this school.
ORDER INFORMATION
Each book contains 50 certificates (MV-278). Specify the number of books you are ordering and the payment amount included:
________ Books of Certificates @ $50 each = $_____________
Payment must be made in full (no partial payment will be accepted) and included with this form.
Payment must be made by check or money order payable to the “Commissioner of Motor Vehicles”.
DO NOT SEND CASH.
CERTIFICATION
I understand that I am required to submit completed rosters to my local Testing and Investigation Unit. I certify that:
·
I have submitted completed rosters to the Testing and Investigation Unit identified below;
·
since my last order, I have submitted to that Unit completed rosters with the date range provided below;
·
since my last order, my school issued the number of Pre-licensing Course Completion Certificates (MV-278) provided below; and,
·
I am authorized to order Pre-licensing Course Completion Certificates.
I certify that the information I have provided on this form is true and complete to the best of my knowledge.
WARNING: Intentionally making a false statement or providing false or misleading information in connection with this
application is a criminal offense that may subject you to criminal prosecution under the Law.
Testing and Investigation Unit: _______________________________________________________________________
Number of Certificates Issued: ___________
Date Range: ___________________________________________
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Authorized Signature (in blue ink):
_________________________________________________________________
*
SEND COMPLETED FORM AND PAYMENT TO:
NYS DEPARTMENT OF MOTOR VEHICLES
PRE-LICENSING PROGRAM
207 GENESEE STREET, SUITE 6
UTICA, NY 13501
A $35.00 FEE WILL BE CHARGED FOR EACH DISHONORED CHECK
MV-278.8 CDS (6/17)
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