HomeMy WebLinkAboutMiscellaneous Application 1989-1-27
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APPLlCATa FOR TYPE I,BUSINESS <ATIFICATE ,..,
.~ ORIGINAL
o RENEWAL *
, AS A DEALER OR REBUILDER OF VEHICLES
NOTE: FAILURE TO ACCURATELY COMPLETE THIS FORM WILL CAUSE UNAVOIDABLE DELAY.
PLEASE TYPE OR PRINT LEGIBLY WITH INK.
(See bottom right corner 01 pag.)
CERTIFICATE NO:
1 NAME (CORPORATION AND/OR ASSUMED BUSINESS NAME)
,;-. =-.. 4- .4-1 . /C)l,) t/ G"
2 MAIN BUSINESS LOCATION (STREET AND NUMBER) CITY ZIP CODE
>'1/'11- R-AL8C-HWOtJ.!J S;flL{I.}{~Fln(j c(7l./7"7
1 MAILING ADDRESS CITY STATE
3':;'lrz t2ALE/6-HwoolJ S(.>I-/N{..FI€W oIL
A SEPARATE SUPPLEMENTAL APPLICATION (FORM 372) MUST BE COMPLETED FOR EACH
ADDITIONAL LOCATION FROM WHICH YOU OPERATE YOUR BUSINESS.
4 CHECK ORGANIZATION TYPE: IIF CORPORATION, LIST THE STATE UNDER WHOSE LAW BUSINESS IS INCORPORATED:
~NDIVlDUAL 0 PARTNERSHIP 0 CORPORATION
'DO YOU SELL THESE VEHICLE TYPES?
BUSINESS TEL;::PHONE
72b-~"SS
COUNTY
LA-N'G"
ZIP CODE
974-77
5 MOBILE HOMES' DYES ~NO
MOTOR HOMES DYES [2i NO
CAMPERS DYES lZf-No
6 ARE YOU A FRANCHISED DEALER? 0
TRAVEL TRAILERS
MOTORCYCLES/MOPEDS
CLASS I A TVS
D YES ~ NO
DYES 'g) NO
DYES ~ NO
SNOWMOBILES
00 YOU REBUILD
VEHICLES?
o YES ~ NO
o YES ~ NO
YES 0 NO
IIF "YES," NAME THE MAKE(S):
I
I
I
I
I
I
I
LIST NAME AND RESIDENCE ADORESS OF ALL INDIVIDUAL OWNERS, PARTNERS OR PRINCIPAL CORPORATE OFFICERS:
7 NAME PUrtY P. 70 ,JAJC;:- TITLE D ' GP- DAT~ OF BIRTH RESIDENCE TELEP~NE
IV/v - CJ- Ii! -1J.7 ($,,"~ \"l'Z (; - 9 Z ?
8 RESIDE~C;~D~.RES~,4 LE /6-/lwocJ!1 CITY p - LA STATE o~ ZIPCOOE <7 74- 7 7
~ IUN6.FIt:.
9 NAME- TITLE DATE OF BIRTH Rr-SIDE~CE TELEPHONE
10 RESIDENCE ADDRESS CITY STATE ZIP CODE
11 NAME TITLE DATE OF BIRTH RfSIDE,\CE TELEPHONE
12 RESIDENCE ADDRESS CITY STATE ZIP CODE
13
14
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.
NAME /J 1 TITLE ~SIDENCE TELEPHONE
(TU-etJ -/OJ..<,)/l/C OW/!/EP--~? (3) lU-67z.z.
ADDRESS, CITY, STATE, ZIP CODE 'SIGNATUR
. ~/9 'L ~AI-Elf:rtfw"()tJ(SPP-liJfrF~G.t-IJ,UL ~7~1JX , _ /fi.. .Dr"'1..f
AGREEMENT TO ACT AS AGENT" Anydealer wno Wants to,bo designa1ed.. an'Agent Of lhe OlvlSklnmust SIgfl~nTenl. By Iew. all Si'lOwmObilllhlnd ClasS I ATV OIaIIr1 must I
" act as.~.nd muSI ~1lJ!l this .Qr..ment. J
I (WE) WISH TO BE DESIGNATED AS A LIMITELJ AGENT FOR THE MOTOR VEHICLES DIVISION. I (WE) AGREE TO COMPLY WITH ALL APPLICABLE I
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.
~GNA TURE I TIT~ I DATE I
15
16
APPROVAL: I CERTIFY THAT THE LOCATION SPECIFIED ABOVE COMPLIES
WITH ALL LAND USE OR BUSINESS REGULATORY ORDINANCES OF THE
)Z\ CITY 0 COUNTY OF
BUSINESS CERTIFICATE FEE (INCLUDES ONE PLATe)
$96.50
ADDITIONALlOCA TIONS @ $30.00 EACH
(SEE ATTACHED SUPPLEMENTAL APPLICATIONS)
ADDITIONAL PLATES @ $11.50 EACH
17 N~~.f\.:n4 j tI L, ~~u ()I'd PFe/rl:Trr{)iNM rll':'
8 SI ~TUR:J . DATE c7
1 X LJ7C'/v.a- (/1 ,nmrlfl'l J -Jl- f /
I CERTIFY THAT I AM AUTHORIZED TO SIGN THIS APPLICATION AND AS
EVIDENCE OF SUCH AUTHORITY DO AFFIX HEREON THE SEAL OR STAMP OF
THE CITY OR COUNTY.
TOTAL: $
* IF THIS IS A RENEWAL OF AN EXISTING CERTIFICATE, USE THE
ATTACHED BILLING LIST TO CALCULATE PLATE FEES.
APPR~~ ~I AM~ UK boAL H"H"I
~!~U THE BILLING LIST MUST BE SUBMITT..:.D WITH YOUR RENEWAL APPLICATION I
CITY .GfJlSlIIHtQ[lBDoN A D SURETY BOND WITH ALL REQUIRED SIGNATURES AND FEES TO:
,
tlU"II'~".. L'l.o NSING UNIT, 1905 LANA AVE. NE, SALEM, OR 97314-2350
735.370 (5.88)
"'-by
STAtE PflINTl".O