VS-114I (4/19)
MV-50 RETAIL/MV-50W WHOLESALE ORDER FORM
dmv.ny.gov
This form may only be used by a dealer who DMV approved for exemption from the VERIFI system.
FACILITY INFORMATION
INSTRUCTIONS
IMPORTANT: You must return a completely used book before we can give you a new book.
To order a new supply of MV-50s or MV-50Ws:
1. sign and date this order and enclose a check or money order payable to
COMMISSIONER
OF MOTOR VEHICLES. DO NOT SEND CASH.
2. write your facility number on your check or money order.
3. optional: If you would like your order returned by express delivery service, add $10.00 to the
total cost of your order.
4. allow 2 - 3 weeks for processing and delivery.
5. enclose this form and the books that are returned in one envelope, and forward the
envelope to:
Write the serial number of each MV-50 or MV-50W book you return with this order form:
Specify the type and number of books you are ordering, and the amount owed:
o Retail @ $250.00 per book o Wholesale @ $125.00 per book
books @ $ each = $
For return express delivery of books, add $10.00 = $
TOTAL PAYMENT AMOUNT = $
A $35.00 FEE WILL BE CHARGED FOR ALL RETURNED CHECKS!
Facility NumberFacility Name
Address City Zip Code
(Authorized Signature)
(Print Name)
(Business Phone)
(E-Mail Address)
(Date)
X
(Quantity)
Regular Mail
Bureau of Consumer &
Facility Services
PO Box 2700
Albany NY 12220-0700
Express (FedEx, UPS, Etc.)
Vehicle Safety Services
6 Empire State Plaza, Room 220
Albany NY 12228
This form may only be used by a dealer who DMV approved for exemption from the VERIFI system.
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