Form 10763 - Aircraft Dealer Registration Application
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1
2State Form 10763
Indiana Department of Revenue
Offi cial Use Only
(R5 / 10-11)
Aircraft Dealer Registration
Dealer Reg. No.
Fiscal content SBA Approved - 1982
Application
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Approved
Denied
Check One:
New Dealer Application
Aircraft Dealer Renewal
If Renewal Enter Dealer Number ____________________________
Indiana Retail Merchant’s Number (Must obtain BEFORE applying)
Federal I.D. Number
Owner name, Legal name, Partnership name, Corporate name or Other entity name -- If sole owner (Last name, First name, Middle
Initial)
Business Trade Name or Doing Business as (DBA) Name
Street Mailing Address #1
Street Mailing Address #2
City
State
Zip Code
E-mail Address
1. Check the type of organization of this Business:
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Sole Owner
Partnership
Corporation
Other (Specify) __________________
2. All corporations please answer the following questions:
A. State of Incorporation ______________________________
B. Date of Incorporation ______________________________
C. State of Commercial Domicile________________________
D. If not incorporated in Indiana enter the date authorized to do business in Indiana _____/_____/____.
Month
Day
Year
E. Accounting period year ending date: ______/______
Month
Day
3. Name(s) of owners, partners, or offi cers:
Name:
Name:
Name:
Title:
Title:
Title:
Address:
Address:
Address:
City:
State:
Zip Code
City:
State:
Zip Code
City:
State:
Zip Code
:
:
:
Social Security Number
Social Security Number
Social Security Number
Attach additional sheets if necessary
4. Name of Contact Person
5. Contact Daytime Telephone Number:
6. Name of Airport of Operation
7. County (of Airport location)
8. Established place of business:
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A. Offi ce located at airport
Yes
No
Offi ce located at residence
Yes
No
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Offi ce located at other facility
Yes
No
Specify other facility location ________________________________
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B. Place of Business has exterior sign identifying dealer by name
Yes
No
C. Advertised as aircraft dealer in the following
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1.
Telephone Book
Yes
No
Email Address ____________________________________
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2.
Internet
Yes
No
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3.
Other
Yes
No
Specify: _________________________________________
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D. Insured or bonded as commercial business in aircraft sales
Yes
No
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Parent category: Financial