Form Mv-175 - Salvage And Assembled Vehicle Inspector Registration
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1
2Georgia Department of Revenue
Salvage and Assembled Vehicle Inspector Registration
Applicants MUST complete all sections of this form legibly, in ink. When completed, sign and return to address listed
below.
SECTION A – APPLICANT INFORMATION
DATE:
Full Legal Name:
Residence Address:
Mailing Address, if different from residence address:
City:
County Name:
Zip Code:
Phone number:
E-mail:
Fax number :
Cell Phone:
Attachments to this application:
Check or money order for $10.00 registration fee
Copy of Drivers License
I-CAR
Platinum Individual
Transcript
TM
®
I-CAR
Student Privacy Waiver (forwarded to I-CAR
)
®
®
$50,000 Surety Bond in favor of the Georgia Department of Revenue
Personal liability insurance in the amount of $1,000,000 / $100,000 per
occurrence
If you are employed full-time at a DOR registered Salvage or Assembled Vehicle
o
Inspection Location, you are not required to maintain personal liability insurance,
however you must provide a letter confirming employment status.
Authorization for Release of Personal Information
I understand and acknowledge that this form will be filed with the Department of Revenue and that it is a
felony, punishable by imprisonment for not fewer than one nor more than three years or a fine of not less
than $1,000.00 nor more than $5,000.00, or both, to knowingly falsify any information on this statement.
Applicant’s Printed Name: ___________________________________________________________________________
Applicant’s
Signature:_______________________________________Date:_________________________________________
Mail completed application all attachments and fees to:
Attn: Salvage Vehicle
M otor Vehicle Processing
Georgia Department of Revenue
P O Box 740381
Atla
nta, GA 30374-03
81
Date Received: ____________________________Approved
Check or Money Order #
Denied
Date ______________________________
______________________
Reason:
MV-175
Page 1 of 2
August 2009
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