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