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INSPECTOR TRAINING APPLICATION - Massachusetts Vehicle Check

By Michelle Myers,2014-05-06 05:48
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INSPECTOR TRAINING APPLICATION - Massachusetts Vehicle Check

    Massachusetts Vehicle Check

    INSPECTOR TRAINING APPLICATION

    55 Messina Dr., Unit C, Braintree, MA 02184

    Please complete ALL sections of this form in INK, sign and mail

    to Massachusetts Vehicle Check at address above, or FAX to

    (781) 849 ā€“ 2967. Incomplete applications will be returned.

     SECTION A Applicant Information PLEASE PRINT

    First Middle Last 1. Applicant Name:

    3. Date of Birth: __ __ / __ __/ __ __ 2. ā€˜Sā€™ Number (Mass Drivers License or State Issued ID):

     MM / DD / YY

     4. Home Address:

    5. City: 6. Zip Code: __ __ __ __ __ -- __ __ __ __ 7. State: 8. Home Phone: ( __ __ __ ) __ __ __ - __ __ __ __ 9. Alternate Phone (optional): ( __ __ __ ) __ __ __ - __ __ __ __

    10. Email (optional):

     SECTION B Training Certifications

    11. Indicate which inspector training course(s) you are applying for: (check ALL that apply)

     11a. Non-commercial 11b. Commercial* 11c. 7D* 11d. Motorcycle

     * Requires successful completion of Non-commercial training

     SECTION C Background Information 12. Are you a current inspector? Yes No 13. If you checked Yes for #12, have you ever had your Inspector Yes No Certification denied, revoked, suspended or placed on probation?

     SECTION D Station Affiliation: List primary Inspection Station with which you will be affiliated. 14. Station Name:

    15. Station ID: ___ ___ ___ ___ ___ ___ ___ ___

    10/22/2008

    I certify under penalty of perjury under the laws of the Commonwealth of Massachusetts that the statements made in this application are true and correct. I agree to abide by the Rules & Regulations set

    forth by the Commonwealth of Massachusetts. I understand that any reports of violations of the Emission

    Inspection Law, or of the Rules and Regulations will be investigated and, if found to be true, could result in

    my decertification as an Inspector or other penalties. Failure to keep my address current with the Registry of Motor Vehicles is a program violation and could result in my license being suspended or revoked.

     Applicant Signature Date

    10/22/2008

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