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HomeMy WebLinkAboutMiscellaneous Application 1990-1-9 PAGE TWO APPLlCA. FOR TYPE I BUSINESS .TIFICATE ' AS A DEALER OR REBUILDER OF VEHICLES 0 ORIGINAL ~ ~~~"~~~':'~OIP"') NOTE: PLEASE READ INSTRUCTIONS ON PAGE ONE BEFORE COMPLETING THIS FORM. FAILURE TO ACCURATELY COMPLETE THIS FORM WILL CAUSE UNAVOIDABLE DELAY. PLEASE TYPE OR PRINT LEGIBLY WITH INK. CERTIFICATE NO: 1 I NAME (CORPORATION AND/OR ASSUMED BUSINESS NAME) , BUSINESS TELEPHONE If c... {()W/V~ COL-[.ECTOIZ.. CfJt2.5 S03-72(p-C,tSS 21 MAIN BUSINESS LOCATION (STREET AND NUMBER) I CITY ZIP CODE COUNTY !?/'(z. R..A LE/6/1w 00'& Ii I/E , SP/!.IAJb-FI.;LIJ 97q.77 LI4,vr:-- I MAILING AOOAESS I CITY STATE I ZIP CODE 3 51Y? RIl[.r;-/6-HwoO!o All!;;, .s1'1L/~FlbUJ 0/2..... ~7l.).7 7 A SEPARATE SUPPLEMENTAL APPLICATION (FORM 372) MUST BE COMPLETED FOR EACH ADDITIONAL LOCATION FROM WHICH YOU OPERATE YOUR BUSINESS. 41 <(!1FCKORGANIZATION TYPE: IIF CORPORATION, LIST THE STATE UNDER WHOSE LAW BUSINESS IS INCORPORATED: ~INDIVIDUAL 0 PARTNERSHIP 0 CORPORATION DO YOU SELL THESE VEHICLE TYPES? 5 MOBILE HOMES MOTOR HOMES CAMPERS o YES III NO o YES ~NO o YES ~NO TRAVEL TRAILERS 0 YES ~ NO MOTORCYCLES/MOPEDS ..EI YES 0 NO CLASS I ATVS 0 YES El NO CLASS III ATVS SNOWMOBILES DO YOU REBUILD VEHICLES? DYES I8f NO DYES f8J NO o YES ~ NO I 6 I ARE YOU A FRANCHISEO DEALER? 0 YES ':80 NO I LIST NAME AND RESIOENCE ADDRESS OF ALL INDIVIDUAL OWNERS, PARTNERS OR PRINCIPAL CORPORATE OFFICERS: 7 I NAME ALLEN /OwAl~ 8 RESIDEl:ICEADDRE$4 sl'1 z.. It.. Lf:/r.-HW.P.P.!L. hilt: , 9 NAME ---.---- 1 0 RESIDENCE ADDRESS 11 12 TITLE 0 /.<JA/FIZ... CITY SPIlIIJ6-F It::t..O TITLE NAME TITLE DATE OF BIRTH RtSIDEN{E TELEPHONE RESIDENCE ADDRESS CITY I STATE ZIP CODE I CERTIFY THAT I AM THE APPLICANT OR AN AUTHORIZED REPRESENTATIVE AND THAT ALL INFORMATION ON THIS APPLICATION IS ACCURATE AND TRUE. I CERTIFY THAT THE BUSINESS DOES OR WILL DEAL IN VEHICLES, OR REBUILDS VEHICLES AND IS OR WILL BE ESTABLISHED AT THE LOCATION GIVEN. 13 NAME- II- - P I TITLE . ( I ~E~DENCE TELEPHONE ' Lt...tFN . 7OLVII/..r 0 W/V f:"(Z.... .r.~ ) 72.b fl:t1PC ?zz 14 ADDRESS,CITY,STATE,ZIPCODE . p /lid I SIGNATURY~9111 '-./ ~ 192 f2.lIuFl6-l-IwoOtJ A';E. SfP"if~'17iJ77 X / 'J<<r: /~ I AGREEMENT TO ACT AS AGENT' Any dealer who want' to be designated as an Aoantolthe Division must sign Ihls lrgtee ent. By law(al1'5n~m~b~.: clasil ATV and Class III ATV . dealers must aCI 8S 8~!.nts and must slltn this spreemanl. II (WE) WISH TO BE DESIGNATED AS A LIMITED AGENT FOR THE MOTOR VEHICLES DIVISION. I (WE) AGREE TO COMPLY WITH ALL APPLICABLE LAWS AND ADMINISTRATIVE RULES AND AGREE TO HOLD THE DIVISION HARMLESS OF ANY LOSS OR EXPENSE RESULTING FROM ANY ACTS OR REPRESENTATIONS IN EXCESS OR IN CONTRAVENTION OF AGENT'S AUTHORITY, AND FROM INCIDENTAL EXPENSES DUE TO TERMINATION. 151 ~GNATURE 1 TITLE I DATE I CITY LOCATION APPROVAL: I CERTIFY THAT THE LOCATION SPECIFIED ABOVe 16 COMPLIES WITH ALL LAND USE OR BUSINESS REGULATORY ORDINANCES OFTHE ~ CITY 0 COUNTY OF ~\P4n.~]d II CERTIFY THAT I AM AUTHORIZED TO SIGN THIS APPLlCATIO AND AS I EVIDENCE OF SUCH AUTHORITY 00 AFFIX HEREON THE SEAL TAMP OF THE CITY OR COUNTY. 171~{)\1\\(. L. ~r\+ ~Cl-n"I~~L~. 18 ~Ut~~ .~, '\lott _ \-'1f-Q6 APPROVED'TAMP OR SEAL HERE) . tin Ut :Ii l\jli~(jEL;; I'F "YES," NAME THE MAKE(S): DATE OF BIRTH (1..-10-47 STATbR- DATE OF BIRTH RESIDENCE TELEPHONE / t:. l~~ \ 71.b-a. t>7ZZ. ZIP CODE '77<) 77 RFSIDE~CE TELEPHONE ZIP CODE STATE BUSINESS CERTifiCATE FEE (INCLUDES ONE PLATE) $96.50 ADDITIONAL LOCATIONS @ $30.00 EACH (SEE ATTACHED SUPPLEMENTAL APPLICATIONS) ADDITIONAL PLATES @ $11.50EACH TOTAL: $ * IF THIS IS A RENEWAL OF AN EXISTING CERTIFICATE, USE T~E ATTACHED BILLING LIST TO CALCULATE PLATE FEES. THE BILLING lIS~MUST BE SUBMITTED WITH YOUR RENEWAL APPLICATION Ptoduc.dby I STATE PAINTING