Form Mv-176 - Application For Salvage And Assembled Vehicle Inspection Location
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3Georgia Department of Revenue
Motor Vehicle Division
Application for Salvage and Assembled Vehicle Inspection Location
This application for a Salvage and Assembled Vehicle Inspection Location shall be completed and accepted by the
Department of Revenue (DOR) prior to any activity related to salvage or assembled vehicle inspections.
SECTION A – STATION LOCATION INFORMATION:
______________________________________________________________________________
BUSINESS NAME
(CORPORATION, LLC, SOLE PROPRIETOR OR PARTNERSHIP)
BUSINESS HOURS OF OPERATION
_____________________________________________________________________________________________
STREET
CITY
STATE ZIP CODE
(NOT A P.O. BOX)
_____________________________________________________________________________________________
BUSINESS PRIMARY PHONE NUMBER
FAX NUMBER
_____________________________________________________________________________________________
POINT OF CONTACT FULL NAME
PRIMARY PHONE NUMBER OR SECONDARY
_____________________________________________________________________________________________
MAILING ADDRESS, IF DIFFERENT
CITY
STATE ZIP CODE
SECTION B– OWNERSHIP/RELATIONSHIP INFORMATION:
CORPORATIONS & LIMITED LIABILITY COMPANIES
LEGAL NAME OF BUSINESS:
_____________________________________________________
LIST PRINCIPAL OFFICERS:
NAME: _______________________________________________ TITLE: _____________________PCT: ______
RESIDENCE ADDRESS:
_____________________________________________________________________________________________
STREET
CITY
STATE ZIP CODE
TELEPHONE
(NOT A P.O. BOX)
NAME: _______________________________________________ TITLE: _____________________PCT: ______
RESIDENCE ADDRESS:
_____________________________________________________________________________________________
STREET
CITY
STATE ZIP CODE
TELEPHONE
(NOT A P.O. BOX)
NAME: _______________________________________________ TITLE: _____________________PCT: ______
RESIDENCE ADDRESS:
____________________________________________________________________________________________
STREET
CITY
STATE ZIP CODE
TELEPHONE
(NOT A P.O. BOX)
Registered Agent: _____________________________________
_____________________________________________________________________________________________
ADDRESS
CITY
STATE ZIP CODE
TELEPHONE
All Shareholders and percentage of ownership, including all minority interests, is required.
You may photocopy this page and provide additional partners and interests.
Form MV-176
Page 1 of 3
August 2009
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