Form 4682 - Application For Dealer, Auction, Or Manufacturer License And Number Plate(S)

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MISSOURI DEPARTMENT OF REVENUE

IMPORTANT NOTICE!

FORM

MOTOR VEHICLE BUREAU - DEALER LICENSING SECTION

Inspection/Certification

(573) 526-3669

4682

APPLICATION FOR DEALER, AUCTION, OR MANUFACTURER

required.

LICENSE AND NUMBER PLATE(S)

(REV. 11-2013)

CAUTION: Due to the form margins, please adjust the page

LICENSE NUMBER (DOR USE)

LICENSE YEAR (DOR USE)

IMPORTANT: Any false statement in this application is a violation of the law and may be punished by fine

scaling setting to "Fit to Printable Area" before printing.

or imprisonment or both. NOTE: You must make a minimum of six sales per year to be eligible for renewal.

Failure to do so may result in an incomplete form.

RETURN COMPLETED APPLICATION TO:

MOTOR VEHICLE BUREAU, DEALER LICENSING SECTION, P.O. BOX 43, 301 WEST HIGH, ROOM 370, JEFFERSON CITY, MISSOURI 65105.

1. BUSINESS NAME

3. NEW DEALERS RECORD ESTIMATE ANNUAL SALES QUANTITIES: _____________

ALL APPLICANTS RECORD NUMBER OF PLATES REQUIRED BY TYPE BASED ON

STREET (PHYSICAL ADDRESS)

TELEPHONE

PREVIOUS SALES/SALES ESTIMATES.

(__ __ __) __ __ __ - __ __ __ __

MOTOR VEHICLE ___________________

POWER SPORT ______________________

CITY

STATE

ZIP CODE

COUNTY

__ __ __ __ __ - __ __ __ __

RV _______________________________

TRAILER ___________________________

COMPLETE IF MAIL TO ADDRESS IS DIFFERENT THAN ABOVE (REQUIRES LETTER FROM POSTAL AUTHORITY)

2. BUSINESS NAME

BOAT _____________________________

BOAT TRAILER ______________________

LICENSURE

PLATE

STREET

FEES: ____________________________

FEES: ______________________________

CITY

STATE

ZIP CODE

BACKGROUND

__ __

__ __ __ __ __ - __ __ __ __

CHECK FEES: ______________________

TOTAL: ___________________________

4. TYPE OF OPERATION(S): (YOU MAY CHECK MULTIPLE BOXES UNLESS YOU ARE A MANUFACTURER OR AUCTION).

A. MV/POWERSPORT DEALER

B. BOAT DEALER

C. MANUFACTURER

D. WHOLESALE MV DEALER

E. BOAT MANUFACTURER

F. WHOLESALE MV AUCTION

G. PUBLIC MV AUCTION

H. TRAILER DEALER

5. TYPE OF UNITS TO BE SOLD/MANUFACTURED. (CHECK ALL THAT APPLY).

A. NEW MVs

B. USED MVs

C. VEHICLE BODIES/CONVERSIONS

D. BOATS

E. NEW/USED TRAILERS

G. NEW/USED POWERSPORTS

I. NEW/USED BOAT TRAILERS

J. RECREATIONAL MVs

K. HISTORIC MVs

L. CLASSIC MVs

M. EMERGENCY VEHICLES

6. (CHECK ONE)

__ __ /__ __ /__ __ __ __

BOND

IRREVOCABLE LETTER OF CREDIT

NUMBER ____________________ COMPANY ________________________________________________________ EXP. DATE

7. LIST FACTORY FRANCHISE TRADE NAMES AND EXPIRATION DATES (ATTACH COPY OF FACTORY FRANCHISE AGREEMENT. CHECK ALL THE CODES WHICH APPLY TO THE FRANCHISE).

P – PASSENGER, T – TRUCK, RV, BUS, M – POWERSPORT (NOT NEEDED FOR TRAILERS AND ATV’S)

MAKE

EXP. MO/YR

__ __ /__ __ __ __

8. TYPE OF OWNERSHIP

1. INDIVIDUAL

2. PARTNERSHIP

3. CORPORATION. (STATE OF INCORPORATION): _____ _____

4. LIMITED LIABILITY CORP.

5. OTHER ____________________

9. HAVE YOU PLEAD GUILTY OR BEEN FOUND GUILTY OF A CRIMINAL OFFENSE WITHIN THE PREVIOUS 10 YEARS?

YES

10. HAS YOUR DEALER/AUCTION/MANUFACTURER’S REGISTRATION EVER BEEN DENIED, SUSPENDED OR REVOKED?

YES

IF YES, GIVE DETAILS ON A SEPARATE SHEET

11. ALL OWNERS, PARTNERS, CORPORATE/COMPANY OFFICERS AND REGISTERED AGENTS MUST BE LISTED BELOW. (ALSO APPLIES TO OUT-OF-STATE CORPORATIONS).

ATTACH EXTRA PAPER IF NEEDED FOR ADDITIONAL OWNERS.

LAST NAME

FIRST

M. INITIAL

SOCIAL SECURITY NUMBER

BIRTHDATE

RESIDENCE ADDRESS

CITY

STATE

ZIP CODE

__ __ __ - __ __ - __ __ __ __

__ __

__ __ __ __ __

__ __ /__ __/ __ __ __ __

__ __ __ - __ __ - __ __ __ __

__ __

__ __ __ __ __

__ __ /__ __/ __ __ __ __

__ __ __ - __ __ - __ __ __ __

__ __

__ __ __ __ __

__ __ /__ __/ __ __ __ __

__ __ __ - __ __ - __ __ __ __

__ __

__ __ __ __ __

__ __ /__ __/ __ __ __ __

I DO SOLEMNLY SWEAR AND AFFIRM THAT THIS APPLICATION IS MADE TO CONDUCT BUSINESS AS A BONA FIDE DEALER, AUCTION, OR MANUFACTURER AS PROVIDED BY SECTIONS 301.550 THROUGH

301.573, RSMo, THAT THE INFORMATION SET FORTH HEREIN IS TRUE AND ACCURATE AND THAT I HAVE THE AUTHORITY TO PROVIDE ALL SUCH INFORMATION AND TO SIGN THIS APPLICATION. THIS

SHALL FURTHER CERTIFY THAT THE BUSINESS SHALL MAINTAIN, DURING THE ENTIRE PERIOD OF REGISTRATION, FINANCIAL RESPONSIBILITY FOR EVERY MOTOR VEHICLE IT OWNS, LICENSES, OR

OPERATES ON THE STREETS AND HIGHWAYS.

12. SIGNATURE OF APPLICANT

DATE

__ __ /__ __/ __ __ __ __

13. INSPECTION/CERTIFICATION REQUIRED?

INSPECTION/CERTIFICATION — SEE REVERSE SIDE FOR WHO MUST COMPLETE THIS SECTION.

I CERTIFY THAT I HAVE PHYSICALLY

INSPECTED THE ABOVE LOCATION AND THAT THE APPLICANT’S BUSINESS QUALIFIES AS A BONA FIDE PLACE OF BUSINESS FOR MANUFACTURING, SELLING,

YES

OR AUCTIONING MOTOR VEHICLES, POWERSPORTS, TRAILERS AND/OR BOATS.

DATE APPROVED

NAME AND RANK