Form Dlb-3a - Application For Motor Vehicle, Trailer Or Motorcycle Salesperson'S License
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1DLB-3A – REVISED 2010
IMPORTANT: Salesperson Wall License and Pocket Card must be issued by this office and in possession by the Dealer before the
applicant may engage in the selling of motor vehicles, trailers or motorcycles.
STATE OF NEBRASKA
NEBRASKA MOTOR VEHICLE INDUSTRY LICENSING BOARD
Application for
FEE $20.00
MOTOR VEHICLE, TRAILER OR MOTORCYCLE SALESPERSON’S LICENSE
Mail to: NEBRASKA MOTOR VEHICLE INDUSTRY LICENSING BOARD, PO BOX 94697, LINCOLN, NE 68509
(402-471-2148)
Applicant’s Name: ____________________________________________________________
________________________________________
(Print or type first, middle and last name)
(Social Security Number)
does hereby make application for a Motor Vehicle, Trailer or Motorcycle Salesperson’s License in accordance with Ch. 60, Art. 14, R.R.S. 1943, as amended,
and in connection herewith makes the following material statements:
1.
Name & Address of Dealership:__________________________________________________________________________________________
2.
Description of applicant is as follows:
Date of Birth _________________________, Sex ______, Color of hair __________, Weight _________, Height _________
3.
Applicant’s home address: ______________________________________________________________________________________________
(Street)
(Town or City)
(State)
(Zip Code)
4.
Applicant’s home phone number (please include area code): (________)_____________________
5.
Has Applicant had a Nebraska Motor Vehicle, Trailer or Motorcycle Salesperson License previously?
YES ______ NO ______
If answer is YES, Year _________. If current year, enclose the current year salesperson’s pocket card with this application, and have the
previous dealer surrender the salesperson’s wall license.
6.
Name of last Nebraska Motor Vehicle, Trailer or Motorcycle Dealer employer: __________________________________________________
7.
(a) Have you ever been found guilty of any felony that has not been pardoned?
YES ______ NO ______
(b) Have you ever been found guilty of any misdemeanor concerning fraud or conversion?
YES ______ NO ______
(c) Have you suffered any judgment in any civil action involving fraud, misrepresentation or conversion?
YES ______ NO ______
(d) Are any felony charges pending against you at the present time?
YES ______ NO ______
If you answered YES to any of the above questions, please give details (attach a separate sheet of paper if needed).
_______________________________________________________________________________________________________________________
)
STATE OF NEBRASKA
)
County of ___________________________
_______________________________________________________, being first duly sworn, upon oath deposes and says: That he/she is the
applicant who makes the above and foregoing application; that he/she has read the same, knows the contents thereof, and that all statements therein
contained are true.
________________________________________________________
(Signature of Applicant)
WARNING: ANY FALSE STATEMENT CAN LEAD TO APPLICATION BEING DENIED, LICENSE BEING SUSPENDED OR
REVOKED, OR MAY SUBJECT YOU UP TO A $5,000.00 FINE.
SUBSCRIBED in my presence and sworn to before me on this ______ day of _______________________, _________
________________________________________________________
(Notary Public)
DEALER MUST COMPLETE THE FOLLOWING CERTIFICATE OF APPOINTMENT:
THIS IS TO CERTIFY THAT _______________________________________________ whose application for a Salesperson’s License is submitted
above has been duly employed by the undersigned as a salesperson to sell motor vehicles, trailers or motorcycles owned by the undersigned.
__________________________________________________
Dealership Name: ________________________________________________
(Signature of owner, partner, LLC member, or corporate officer)
__________________________________________________________________________
Dealer License Number: ___________________
(Printed name of owner, partner, member, or corporate officer & title)
IMPORTANT: Certified check, postal money order or cashier’s check, in the proper amount, made payable to NEBRASKA MOTOR
VEHICLE INDUSTRY LICENSING BOARD, must accompany this application. PLEASE DO NOT SEND CURRENCY.
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