Form Rdmv 996 -Vehicle Dealer Owner Registration
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1State of New Hampshire
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES
STEPHEN E. MERRILL BUILDING
John J. Barthelmes
23 HAZEN DRIVE, CONCORD, NH 03305
Elizabeth Bielecki
Commissioner of Safety
Telephone: (603)227-4000 TDD Access Relay NH 7-1-1
Director of Motor Vehicles
DEALER NUMBER: ________________________
DEALER CORPORATE NAME:__________________________________________________
DEALER TRADE NAME:________________________________________________________
MAILING ADDRESS:___________________________________________________________
LEGAL ADDRESS:_____________________________________________________________
TELEPHONE NUMBER:________________________________________________________
OWNER’S NAME______________________________________________________________
AUTHORIZED NEW HAMPSHIRE INSPECTION STATION NUMBER:___________________
STATION NAME:______________________________________________________________
MAILING ADDRESS:___________________________________________________________
LEGAL ADDRESS:_____________________________________________________________
TELEPHONE NUMBER:________________________________________________________
OWNER’S NAME:_____________________________________________________________
261:103-a (e) A duly executed service agreement on forms provided by the department with a service or repair
garage which is a licensed inspection facility within a reasonable distance from the applicant's established place of
business, if applicant does not have facilities at the applicant's established place of business to service or repair
motor vehicles.
The below owners signatures of the aforementioned facilities, have entered into this service
agreement to inspect, service or repair motor vehicles for the specified dealer, to expire upon
dealer license expiration.
Immediate notification is required, in writing, if there is any interruption of service or cancellation
of this agreement.
The undersigned of this service agreement understand and certify that ANY FALSE
STATEMENTS ARE PUNISHABLE UNDER RSA 641.3
DEALER OWNER SIGNATURE:__________________________________________________
DEALER OWNER PRINTED NAME:_______________________________________________
DATE:_________________________
INSPECTION STATION OWNER SIGNATURE:______________________________________
INSPECTION STATION OWNER PRINTED NAME:___________________________________
DATE:_________________________
RDMV 96 (Rev. 8/17)
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