Form Mv-176 - Application For Salvage And Assembled Vehicle Inspection Location (Page 3 of 3) in pdf

Georgia Department of Revenue

Motor Vehicle Division

Application for Salvage and Assembled Vehicle Inspection Location

I understand that the Georgia Department of Revenue may periodically check the tax and Georgia

criminal history information at any time during my term without seeking additional consent from me. I do

hereby authorize a review and full disclosure of all records concerning myself to any duly authorized

agent of the Georgia Department of Revenue Special Investigations Unit, whether such records are of a

public, private, or confidential nature for criminal history and tax records.

I understand that any information obtained by a personal history background investigation, which is

developed directly or indirectly, in whole or in part, upon this release authorization, will be used in

determining my suitability for Department of Revenue registration in a position of trust. I authorize the

disclosure of the aforementioned personal information to any person(s) deemed by the Georgia

Department of Revenue to be a participant in the determination process of such suitability. I also certify

that any person(s) who may furnish such information concerning me shall not be held accountable for

giving this information; and I do hereby release said person(s) from any and all liability which may be

incurred as a result of furnishing such information. I understand that information obtained with this

authorization may be subject to public disclosure pursuant to the Georgia Open Records Act (O.C.G.A. §

50-18-70 et seq.)

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.

Signature(s) of Individual, Partners (All Required), Authorized Corporate Officer

________________________________________________

DATE___________________________

Signature

_______________________________________________

________________________________

Print Name

Position

________________________________________________

DATE___________________________

Signature

________________________________________________

________________________________

Print Name

Position

WITNESS:

________________________________________________

DATE___________________________

Signature

________________________________________________

___________________________

Printed Name

Position

Submit completed application, signed with all attachments and fees to:

GA Department of Revenue

Title Processing

P. O. Box 740381

ATLANTA, GA 30374-0381

Date Received: ____________________________Approved

Check or money order #

Denied

Date ______________________________

____________________________

Reason:

Form MV-176

Page 3 of 3

August 2009

Form Mv-176 - Application For Salvage And Assembled Vehicle Inspection Location Page 3

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