HomeMy WebLinkAboutBusiness License Application 1985-12-29
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APPL. TION FOR BUSINESS CERT*A TE
AS A DEALER OR REBUILDER OF VEHICLES (EXCEPT SNOWMOBIL-';D ATV'S)
CERTIFICATE NO,' 1::?(/,O
o ORIGINAL
pit RENEWAL
NOTES: FAILURE TO ACCURATELY COMPLETE THIS FORM WILL CAUSE UNAVOIDABLE DELAY
PLEASE.TYPE OR PRINT LEGIBLY WITH INK
DO NOT SUBMIT APPLICATION WITHOUT YOUR SURETY BOND AND THE REQUIRED FEE.
I NAME (CO~ATION AND/OR ASSUMED ~INESS NAME)
. (/1,A'i(I/,4.t(,3.. (--rh<:'-M/J('/z/d6.-2dC.
I MAIN BUSINESS LOCATION (STREET AND NUMBER) CITY
/---(17 &. /l P,-r. l~f1^",/.ur;F/b;(l>
I MAILING ADDRESS CITY
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LIST THE AOORESSES OF ALL AOOITIONAL BUSINESS LOCATIONS, A SEPARATE APPLICATION (FORM 371) MUST BE COMPLETEO FOR
ANY AOOITIONAL LOCATIONS /N A OIFFERENT CITY OR COUNTY,
ISTR/~;q 0). 7;r/i /JI/t5: 'EzlhAd6 197;0,,1 1%':t6" J;;;,f~a?'
I STREET ADORESS CITY I ZIP CODE I COUNTY I TELEPHONE
I CHECK ORGANIZATION TYPE: IF CORPORATION. LIST THE STATE UNDER WHOSE LAW BUSINESS 1$ INCORPORATED
o IND/VIDUAL 0 PARTNERSHIP {SCORPORATlON (()/E/50/,)
I LIST NAME ANO RESIOENCE ADORESS OF ALL INOIVIDUAL OWNERS, PARTNERS OR PRINCIPAL CORPORATE OFFICERS
I NAM~ TITLE DATE OF BIRTH RESIDENCE TELEPHONE
AJJJ.fJiI V ~///-3(U/ ?U,(SS //-/C-5L/" (~~'t 7.y~~..39.y9
I RESIDEN9EtADORESS . CITY . . ST~ ZIP CODE
Y'('),:q~. (')0-1'# 37:'- l3t'//t'J6?75A:~ (' )~. 97<;/7;?
I NAME TITLE DATE OF BIRTH -~ .oR-E"sIDENce"TELEPHONE
Ud'I,"0;<J /J(. "::;;:;;(///(Z,O-f/>7'rY J':f>6A8 9-~s/ (\"5~H '7~-39-0)
I RESIDEN9J',ADDRESS CITY' S~ ZI':~O;;;....;'.,....o
YO~ ~,._&-r;(I.?-.i: 8"P/,/..(5)C/6..(\ ('(.-//, y", 7/n
I NAME TiTLE----.--.--- DATEOFBIRTH ~ESIDE~CETELEPHONE~
I RESIDENCE ADORE.55 CITY STATE ZIP CODE
ARE YOU A FRANCHISEO DEALER? 0 YES IF YES, NAME THE MAKE(S): 0 CHECK IF YOU SELL MOBILE HOMES
-{;3 NO 0 CHECK IF YOU REBUltO VEHICLES
I CERTIFY THAT I AM THE APPLICANT OR AN AUTHORIZED REPRESENTATIVE ANO THAT ALL INFORMATION ON THIS APPLICATION IS
ACCURATE ANO TRUE, I CERTIFY THAT THE BUSINESS DOES OR WILL DEAL IN, OR REBUILDS VEHICLES ANO IS OR WILL BE ESTABLISHED
AT THE LOCATION(S) GIVEN,
-NAME ~ -r-: I TITLE,........;) I RESIDENCE TE.JLE~ONE'
..A/lA'.PrI 1/ -/t'J7{///$}1d/ ' ;/'/'b!-? A 601) 7%~( .1)9/9
IADDREss,crrv,sTATE,ZIPCODE d I~GNATWd'/ / /
9z;~ ,<:0 (~ 2r ' . x ~K./~
AGREEMENT TO ACT AS AGENT: I (WE) WISH TO BE DESIGNATEO AS A L1MITEO AGE FOR"f~OTOR VEHICLES DIVISIO!'l.1 (WE) AGREE
TO COMPLY WITH ALL APPLICABLE LAWS ANO AOMINISTRA TIVE RULES ANO AGREE TO HOI!6 THE DIVISION HARMLESS OF ANY LOSS OR
EXPENSE RESULTING FROM ANY ACTS OR REPRESENTATIONS IN EXCESS OR IN CONTRAVENTION OF AGENT'S AUTHORITY, ANO FROM
INCIOENTAL EXPENSES DUE TO TERMINATION,
A ,
I ~GNA TUR
ApP VAL'
-d.H ALL
l"CITY
ZIP coDe
97-</77
STATE
BUSINESS TELEPHONE
7.y7-0)fd19
COUNM.ulb
ZIP coDe
IFY THAT EACH LOCATION SPECIFIED ABove COMPLIES
USE OR BUSINESS REGULATOR N~CES OF THE n -- BUSINESS CERTIFICATE FEE (INCLUDES ONE PLATE)
COUNTY OF
G /
. ADDiTIONAL LOCATIONS @.S30.00EACH
I CERTIFY THAT I AM AUTHORIZED TdJ)IG TH AP ICATION AND AS
EVIDENCE OF SUCH AUTHORITY 00 AFd1ERE N TH EAL OR STAMP OF
THE CITY OR COUNTY, . -..' v.,lJt~~g.p.ADdbV
~~II : J'TITLE
ftnM-/A- :.4, ' /YlC('h4ti?/J~ /-~~
G'fI1JE II . '11. " DATE
~-/ l/J1dtl~CESiA~:~L'1e~A~
- ADDITIONAL PLA Tfc
eX
17J'-v11-B5
.-.., $96.00
c5o, iXJ
@ $11:00 EACH a.5i'- 00
/#'-%L~
ITlTLEy~:
TOT Ale $
NOTE: IF THIS IS A RENEWAL OF AN EXISTING CERTIFICATE USE THE
::::. ",ATTACHED BILLING LIST TO CALCULATE PLATE FEES...
735-370 (1 0-85)
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