Form Dlb-8a - Application For Distributor, Manufacturer, Nebraska Factory Branch - Motor Vehicle Or Trailer License
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1DLB-8A Revised 2010
State of Nebraska
NEBRASKA MOTOR VEHICLE INDUSTRY LICENSING BOARD
301 CENTENNIAL MALL SOUTH, P. O. BOX 94697
LINCOLN NE 68509
Telephone: (402) 471-2148
Website:
Indicate the type of license for which application is being made:
___ MOTOR VEHICLE OR TRAILER DISTRIBUTOR LICENSE
FEE $ 425.00
___ MOTOR VEHICLE OR TRAILER MANUFACTURER LICENSE
FEE $ 425.00
___ MOTOR VEHICLE OR TRAILER NEBRASKA FACTORY BRANCH LICENSE
FEE $ 50.00
Each Manufacturer who maintains a Factory Branch in this State must license both the Manufacturer and Factory Branch in accordance
with Ch. 60, art. 14, R.R.S., 1943, as amended.
Applicant will comply with and be subject to the Motor Vehicle Industry Regulation Act, the rules and regulations adopted and
promulgated by the Board, and any amendments to the act and the rules and regulations existing on the date of the application.
1. Firm name under which business is conducted: ____________________________________________________________
Address: ___________________________________________________________________________________________
Street
PO Box
City
State
Zip
Telephone number: (____) ___________________
FAX number: (____) ___________________
2. Provide the name(s) and address(es) of the owner. Check only one ownership type.
__ Individual: Name and address of individual owner ____________________________________________________
Social Security Number: _____________________________
__ Partnership: Names and addresses of partners
_________________________________________________________
____________________________________________________________________________________________________
__ Corporation or LLC
(Corporation name or LLC if different than the name under which the business is conducted):
___________________________________________________________________________________________
List below the names, addresses and titles of the principal officers of the corporation or members of the LLC
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
3. Line Make or Name under which motor vehicles or trailers are marketed (please do not include model names):
______________________________________________________________________________________________
______________________________________________________________________________________________
THIS APPLICATION MUST BE SIGNED AND NOTARIZED
)
STATE OF _______________________
)
County of ________________________
__________________________________________________, being first duly sworn, upon oath deposes and says: That he/she is the applicant
(printed name of owner, partners, corporate officer or member)
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)
(Signature of Applicant)
SUBSCRIBED in my presence and sworn to before me this _______day of ____________________, __________
______________________________________________
(Notary Public)
A certified check, postal money order or cashier’s check in the proper amount made payable to the NEBRASKA
MOTOR VEHICLE INDUSTRY LICENSING BOARD must accompany this application.
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Parent category: Financial