SR-E-5067E (2018/04) © Queen's Printer for Ontario, 2018 Disponible en français Page 1 of 3

Ministry of Transportation

Motor Vehicle Inspection Station (MVIS) UnitMVIS Licence Replacement/Amendment

InstructionsIf you are an individual with an Ontario driver’s licence, please visit a ServiceOntario Centre to request changes to your name, address, date of birth or gender.For name and address changes:

If the MVIS client is a Corporation, this application must be signed by one of the business owners/partners/corporate officers. If the MVIS client is a Multi-Party, this application must be signed by both members. If the MVIS client is an Individual, this application must be signed by the individual, a trustee, an executor or administrator of the Estate.Complete this form to request a replacement MVIS Licence, make changes to the station name, address, class or type and to update client information.Sections 1, 5 & 6 must be completed for all requests For replacement of an MVIS licence, please complete Section 2. To request an amendment to your MVIS licence, please complete Section 3. If you require changes to your client information, please complete Section 4.Complete and send to:

The Ministry of Transportation MVIS Unit 301 St. Paul Street, 8th Floor St. Catharines ON L2R 7R4 Fax 905-704-2574

For additional information visit www.mto.gov.on.ca or call 416-246-7166 or 1-800-387-7736.

Section 1 - Client DetailsMVIS Licence Number

Legal Name (Corporation Name)/Last Name (Individual) First Name

Middle Name Operating As (Registered Trade Name)

Telephone Number

ext.

Fax Number Email Address

AddressUnit Number Street Number Street Name PO Box

City/Town/Township Province/State Postal/ZIP Code Country

Section 2 - Replacement Motor Vehicle Inspection Station (MVIS) LicenceLicensee Name MVIS Licence Number

Reason For Replacement (Please select one)

Never Received (No Charge) Lost/Stolen/Destroyed ($5.00 Charge)

Section 3 - Amendment to Motor Vehicle Inspection Station (MVIS) LicenceLicensee Name MVIS Licence Number

Change of Licence Class (Please select one)

Change to Class F ($5.00 Charge) Change to Class P ($5.00 Charge)

Change/Add/Delete Licence TypeNote: If changing or adding Station Type 6, a site inspection from a Ministry of Transportation representative is required before amendments to the licence will be made. Change From Type(s) To Type(s)

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Change of Station NameNew Station Name

Change Station Physical AddressUnit/Apt/Suite Number Street Number Street Name PO Box

Lot Number Concession Township City/Town/Village

Province Postal Code/Zip Code Country

Telephone Numberext.

Email Address Fax Number

Note: If changing the physical address of the station, a site inspection from a Ministry of Transportation representative is required before amendments to the licence will be made. Additional supporting documents are required when changing physical location. Please attach to this application.

1. Appropriate zoning information from City / Province, provide one of the following documents

Zoning Compliance Occupancy Permit Business Licence Letter of Conformity

2. If property owned, provide Deed or Mortgage

3. If property leased, provide the Property Lease Agreement

Change Station Mailing AddressUnit/Apt/Suite Number Street Number Street Name PO Box

Lot Number Concession Township City/Town/Village

Province Postal Code/Zip Code Country

Telephone Numberext.

Email Address Fax Number

Section 4 - Change of Client InformationLegal Name (Corporation Name)/Last Name (Individual) First Name

Middle Name Operating As (Registered Trade Name)

Date of Birth (yyyy/mm/dd) Gender Telephone Number

ext.

Alternate Telephone Number

Mobile Telephone Number Fax Number Email Address

Preferred Language Preferred Method of Communication

AddressUnit Number Street Number Street Name PO Box

City/Town/Township Province/State Postal/ZIP Code Country

Mailing AddressUnit Number Street Number Street Name PO Box

City/Town/Township Province/State Postal/ZIP Code Country

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Section 5 - Fees and Method of PaymentFeesTotal Fees

All personal cheques must be certified unless payment is sent by mail

Cheque Make payable to the "Minister of Finance/MTO". Please note that we do not accept post dated cheques.

Amount ($) Credit Card Please fill in and attach the Credit Card Authorization Form (SR-LV-034).

Amount ($)

Stored Credit Amount ($) Certified Cheque Make payable to the "Minister of Finance/MTO".

Amount ($)

Money Order Make payable to the "Minister of Finance/MTO".

Amount ($) Prepaid Account Amount ($)

Section 6 – Signature

Note: Under provincial legislation, a false statement from the applicant may result in a penalty

Information in this application is collected under the authority of section 91 of the Ontario Highway Traffic Act and Ontario Reg 601 and is used to establish the eligibility for a Motor Vehicle Inspection Station Licence. Direct enquiries to the Ministry of Transportation, Carrier Sanctions and Investigation Office, 301 St. Paul Street, 3rd Floor, St. Catharines, Ontario L2R 7R4, 1-800-387-7736 or 416-246-7166.Authorized Name Authorized Signature Date (yyyy/mm/dd)