Form Bls 14 - Application For New Car Inspection Stickers Page 2
ADVERTISEMENT
1
2Have the owners, partners or officers, agents or employees of your organization ever used an alias or been known by any other name?
8.
[ ] Yes
If yes, explain: ______________________________________________________________________________________________
[ ] No
_____________________________________________________________________________________________________________________________________________
Do you intend to employ a person who has been convicted of a criminal or disorderly person’s offense in this or any other state?
9.
[ ] Yes
If yes, explain: ______________________________________________________________________________________________
Print name and address of person
[ ] No
_____________________________________________________________________________________________________________________________________________
Have any of the applicant’s owners, partners or officers ever held any Motor Vehicle Commission business licenses?
10.
[ ] Yes
If yes, Type of License ____________________________________________
License Number ______________________________
[ ] No
(Add additional sheet if needed.)
Have the license(s) identified in question 10 ever been suspended or revoked by the Motor Vehicle Commission?
11.
[ ] Yes
If yes, explain: _______________________________________________________________________________________________________
[ ] No
__________________________________________________________________________________________________________________________________________________________
12. Has the person conducting the inspection completed pre-delivery inspection training?
[ ] Yes
If yes, where completed: ______________________________________________________________________________________________
Date completed: _____________________________________________
[ ] No
If no, explain: ___________________________________________________________________________________________
The undersigned hereby certifies that the above information is true and that if any of the above information is willfully false, the
undersigned is subject to punishment. The undersigned further understands that any untruthful representation or any violation of the
applicable statutes and regulations promulgated by the Commission shall be reasonable and proper grounds for privilege suspension or
revocation. The undersigned further agrees to notify the Commission immediately of any change in the status of the business or of any other
information that would alter the answers and statements in this application or any supplement(s) thereto.
I, the undersigned, hereby certify that I am _______________________________________________ of the above business previously named
Owner, Partner, Officer, Member
that the information I have submitted is true to the best of my knowledge.
____________________________________________________________ and
Business Name
_________________________________________
____________________________________
____________________
___________
Print Name
Signature
Title
Date
I, the undersigned, hereby certify that I am Secretary / Member / Partner of the above business and have witnessed the signature of
_______________________________
who is ____________________________________________________ of said business.
Print Name
Owner, Partner, Officer, Member
___________________________________________________________
__________________________
_______________________
Signature
Title
Date
BLS 143 (R09/15)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal