Form Mv-176 - Application For Salvage And Assembled Vehicle Inspection Location Page 2
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3Georgia Department of Revenue
Motor Vehicle Division
Application for Salvage and Assembled Vehicle Inspection Location
SOLE PROPRIETORSHIP or PARTNERSHIP
OWNER NAME: ______________________________________________________
RESIDENCE:
_____________________________________________________________________________________________
STREET
CITY
STATE ZIP CODE
TELEPHONE
(NOT A P.O. BOX)
LIST ALL PARTNERS:
NAME: _______________________________________________ TITLE: ________________________
RESIDENCE ADDRESS:
_____________________________________________________________________________________________
STREET
CITY
STATE ZIP CODE
TELEPHONE
(NOT A P.O. BOX)
NAME: _______________________________________________ TITLE: ________________________
RESIDENCE ADDRESS:
_____________________________________________________________________________________________
STREET
CITY
STATE ZIP CODE
TELEPHONE
(NOT A P.O. BOX)
You may photocopy this page and provide all additional partners and interest holders.
SECTION C– STATION OPERATIONAL INFORMATION
All questions must be answered:
Indoor service bay?
YES
Safe and secure parking for customers?
YES
Indoor waiting area for customers?
YES
Is the location on a state road or highway that will permit the maximum load of any vehicle traveling to this
location?
YES
DOR is under no obligation to provide an inspector at this location and any schedule provided by DOR for
a DOR employed salvage inspector is subject to change at any time. The station point of contact is
responsible for keeping all potential vehicle owners informed of their respective location schedule.
Employing Private Salvage Station Inspectors?
YES
Attach or forward Salvage Vehicle Inspector Application Form MV 175 with all attachments
o
The Private Salvage Inspector information must be updated within 10 days and sent to DOR with
each change.
SECTION D – ATTACHMENTS TO BE INCLUDED WITH THIS APPLICATION
Check or money order $100.00 registration fee
Certificate of Insurance - $1,000,000.00 aggregate / $100,000 per occurrence
Copy of State Tax Identification Registratio
n Certificate
DOR Salvage Vehicle Location Agreement
Copy of Owner, all Partn
ers and Corporate Officers Drivers License
Form MV-176
Page 2 of 3
August 2009
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