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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 781 849 2967. Incomplete applications will be returned. SECTION A Applicant Information 1. Applicant Name PLEASE PRINT First Middle Last 3. Date of Birth 2. S Number Mass Drivers License or State Issued ID / / MM / DD YY 4. Home Address 5. 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 781 849 2967. Incomplete applications will be returned* SECTION A Applicant Information 1. Applicant Name PLEASE PRINT First Middle Last 3. Date of Birth 2. S 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 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 Background Information 12. Are you a current inspector Yes 13. If you checked Yes for 12 have you ever had your Inspector Certification denied revoked suspended or placed on probation No Station Affiliation List primary Inspection Station with which you will be affiliated* 14. Station Name 15. Station ID 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* Date Applicant Signature 10/22/2008. 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 781 849 2967. Incomplete applications will be returned* SECTION A Applicant Information 1. Applicant Name PLEASE PRINT First Middle Last 3. Incomplete applications will be returned* SECTION A Applicant Information 1. Applicant Name PLEASE PRINT First Middle Last 3. Date of Birth 2. S Number Mass Drivers License or State Issued ID / / MM / DD YY 4. Home Address 5. Date of Birth 2. S 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 Training Certifications 11. City 6. Zip Code -- 7. State 8. Home Phone - 9. Alternate Phone optional - 10. Email optional Training Certifications 11. Indicate which inspector training course s you are applying for check ALL that apply 11a* Non-commercial 11b.

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