Indiana Public Auto Auction - Dealer Registration Packet (Page 5 of 8) in pdf

Indiana Public Auto Auction - Dealer Registration Packet Page 5

The following person(s) is (are) authorized agent(s) to buy/sell on behalf of Dealer.

Name of Authorized Agent:__________________________________ Date of Birth_________________________

SS#__________________ Drivers License #_____________________ State ________ Cell #_________________

__________

Home Address________________________________________ City_____________ State _____ Zip

Signature of Authorized Agent____________________________________________________________________

Signature of Officer, Partner or Owner______________________________________________________________

Printed Name and Title__________________________________________________________________________

Name of Authorized Agent:__________________________________ Date of Birth_________________________

SS#__________________ Drivers License #_____________________ State ________ Cell #_________________

__________

Home Address________________________________________ City_____________ State _____ Zip

Signature of Authorized Agent____________________________________________________________________

Signature of Officer, Partner or Owner______________________________________________________________

Printed Name and Title__________________________________________________________________________

Name of Authorized Agent:__________________________________ Date of Birth_________________________

SS#__________________ Drivers License #_____________________ State ________ Cell #_________________

__________

Home Address________________________________________ City_____________ State _____ Zip

Signature of Authorized Agent____________________________________________________________________

Signature of Officer, Partner or Owner______________________________________________________________

Printed Name and Title__________________________________________________________________________

By_____________________________________________

Date_______________________________________

Printed______________________________________

Title___________________________________

If paying by company check, I agree that “IPAA” is authorized at any time to obtain a credit report and/or criminal

background check on each entity signing this form.

Page 5 of 8

Indiana Public Auto Auction - Dealer Registration Packet Page 5