HomeMy WebLinkAboutApplication APPLICANT 9/13/2010
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SIGNATURE OF PERSON CERTIFYING
16 X
17
18
19
20
21
11
12
13
14
15
22
23
;....
OWNERSHIP CHANGE
Check your organization type on line 11, Jist all owners and provide other required information below. Your dealer
number and expiration date will stay the same. If adding names, please attach (staple) copies of ALL new owners,
partners, LLC members or corporate officers official photo 10's (driver license or state issued identification card ONLY).
Copy must be legible. If the residence address on the photo 10 is different than the residence address listed below,
submit a statement explaining why the addresses do not match.
o Individual 0 Partnership LC 0 Corporation (If corporation, under whose law is business incorporated?)
[~D NAME~]
List each person being added as a partner, LLC member or corporate officer.
PRINT NAME (MUST SIGN UNE 16) TInE
DATE OF BIRTH
ORIVER UCENSE NUMBER
STAlE OF ISSUE HOME PHONE NUMBER
( )
CITY STATE ZlPCODE
CITY STATE ZIP CODE
DATE
TITlE
STATE OF ISSUE
CITY ZIP CODE
CITY STATE Z1PCOOE
DATE
RESIDENCE ADDRESS
MAIUNG ADDRESS
PAINT MAIlE (MUST SIGN LINE 21)
DATE OF BIRTH
DRIVER UCENSE NUMBER
RESIDENCE ADDRESS
MAILING ADDRESS
SIGNATURE OF PERSON CERTIFYJHQ
List each person being removed as a partner, LLC member or corporate officer.
SIGNATURE Tm.E
X
PRINT NAME
PRINT NAME
SIGNATURE
TITlE
X
CERTIFICATION
False certification is a Class B misdemeanor under ORS 162.085, and is punishable by six months in jail, a line of up
to $1,000 or both. In addition, civil penalties of up to $1,000 and OMV sanctions against you or your dealer certificate
may be imposed. With the above penalties in mind:
I CERTIFY J am an owner, partner, LLC member or corporate officer of this dealership and all information on this
application is accurate. I give consent for OMV to check my name through OSP Central Bureau of Criminal
Investigation,.Bn.d to check OMV records to determine whether I owe money on an outstanding civil penalty.
SKlNA e OF PERSON CERTIFYING TInE
24 X' ~.-
25 BOND ENDORSEMENT LIABILITY ENDORSEMENT
26
Attach rider from bonding company
Attach new certificate of Insurance from
Insurance company
lIEI'MnlI!N'TOI'TIINIif'ORTAIIOII
lIIlM!lllUCl.:n'Olt~BEIMl:I8
_L.uu.AVI!~UlPIOIIEDl)Ilfn14
APPLICATION TO CORRECT DEALER I REBUILDER
VEHICLE DEALER CERTIFICATE
5"
C HE BUSIN 5S rfAME I
INSTRUCTIONS: ' 10 Jt< 'eS de
Use this form for a name change, address change, name and address change, add or remove an owner, partner, LlC member or
corporate officer, and change type of organization (like LLC to corporation, partner to corporation). Complete both sides of this form
and submit it to OMV Business Ucense Unit, 1905 Lana Ave NE, Salem Oregon 97314. NOTE: If the dealership has been sold, the new
owner(s) must obtain their own vehicle dealer certificate using Form 370 Packet since a vehicle dealer qertificate is not transferable.
. The fee for a corrected certificate to change your business name, VALIDATION USE ONLY
location, organization structure or to add/remove owners is $30.
. The fee for a corrected certificate to change your business name AND
location is $60.
. Each new owner must complete and sign Lines 12-16 or 17-21.
. Each owner being removed must sign Line 22 or 23.
. One owner must sign Line 24.
. Provide copy of photo 10 If changing residence address.
. Your dealer number and expiration date will stay the same.
Check the reason you are applying for a correction: III" 00 Name Ch.nge ($30)21 Add.... Change ($30) 0 Add. , Removing Owners ($30)
Name . Add.... Change ($80) 0 all!. , Structu.. Chango ($30)
EFFECTIVE DATE
EXPIRATION DATE
CUSTOMER NUMBER
1
NEW BUSINESS NAME (If assumed business name, fill in RegIstry Number.)
OREGON REGISTRY NUMBER
BUSINESS TELEPHONE
( )
2
Any alteration of LIne 3 voids location approval.
- AD RE CH
o RESIDENCE 0 PREVIOUS SUPPLEMENTAL
0(2 97'{7
P CODE
CITY
G
/A.'P
,?...c~
ZIP CODE
'77'/0'.:;)
ZIP CODE
CITY
PREVIOUS LOCATION
-7V( //~ errs
. LOCATION APPROVAL. R ulred ani If dealer Is chan In business location
Certification of local Zoning and Business Regulatory Compliance. OAS 822.005 requires a vehicle dealer license, unless exempt under ORS 822.015, for any
person who:
(a) Buys, sells, brokers, trades or exchanges vehicles either outright or by means of any condltionai sale, baltment, lease, security interest, consignment or
otherwise; OR
(b) Displays a new or used vehicle, trailer or semitrailer, OR
(c) Acts as any type of egent for the owner of a vehicle to sell the vehicle or acts as any type of agent for a person interested in buying a vehicle to buy a vehicle.
THE CERTIFiCATION BELOW IS TO BE COMPLETED BY THE lOCAl ZONING OFACIAL Your spproval below should be based upon whether the spplicant can
do ANY of the activities listed in (a) through (c) above under your ordinances, at the iocation of the business given on Une 3. Pursuant to ORS 822.025(6)(b)(A)(B),
applicant meets requiremente below.
As the zoning official for the locality in which this business is located, I verify by my signature below that the iocation of this business as stated on this spplication,
complies with any land use ordinances and business ulatory ordinances of the ci or coun ,as repriate pursuant to ORS822.025.6(a)
TELEPHONE NUM ER
CITY
~
ZIP COOE Lh
r77(:J~-
8
9
10
D COUNTY OF:
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APPROVED
CITY OF SPRINGFIELD
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