Form 5306 - Authorization And Release For License Office Management, New Personnel, And Officers Page 2

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This section must be completed by Current and Prospective License Office Employees, Officers, and Presiding Officers.

Do you own a business or are you an officer of a business for which you are responsible for the payment of:

Missouri Sales and Use Tax?

Yes

Corporate Income Tax?

Yes

If yes to either of the above, complete the information below for each business owned and for each motor vehicle, trailer, ATV, vessel

and outboard motor owned, co-owned, or leased by the business, if the business is responsible for the registration and payment of

personal property taxes on such leased unit. Attach additional sheets if necessary.

Business 1

Does the business have employees?

Doing Business As (DBA) Name

Yes

Legal Name of Business on File with the Internal Revenue Service (IRS) Contact Person

IRS Form 1099 Mailing Address

City

State

Zip Code

Telephone Number

Fax Number

Charter or Certificate of Authority Number

(

)

(

)

___ ___ ___

___ ___ ___ ___

___ ___ ___

___ ___ ___ ___

E-mail Address

Federal Employer I.D. Number

Missouri Tax I.D. or Exemption Number

Vehicle Identification Number or Missouri Title Number

Year

Make and Model

Business 2

Does the business have employees?

Doing Business As (DBA) Name

Yes

Legal Name of Business on File with the Internal Revenue Service (IRS) Contact Person

IRS Form 1099 Mailing Address

City

State

Zip Code

Telephone Number

Fax Number

Charter or Certificate of Authority Number

(

)

(

)

___ ___ ___

___ ___ ___ ___

___ ___ ___

___ ___ ___ ___

E-mail Address

Federal Employer I.D. Number

Missouri Tax I.D. or Exemption Number

Vehicle Identification Number or Missouri Title Number

Year

Make and Model

This section must be completed by all applicants.

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. By my signature below, I hereby

authorize the Missouri Department of Revenue (Department) to check for compliance for at least the last five years: (1) my Federal and Missouri tax records

including, but not limited to, individual income tax, corporate tax, sales and use tax, withholding tax, and employment security tax pertaining to me personally (and

my spouse, if married and filing combined returns) and to any corporations, partnerships or companies of which I am an owner or may be a responsible person or

officer; (2) the title and registration records on all vehicles, trailers, ATVs, vessels, and outboard motors (units) that I and any business for which I am responsible

owns or co-owns for proper registration as well as those units leased by the applicant or business, if the applicant or business is responsible for the registration and

payment of personal property taxes on such leased units and any outstanding sales and use tax delinquencies; and (3) my personal property tax payment records on

the above units. I do hereby release the State of Missouri, Department of Revenue, and other persons, firms, corporations, and institutions from any and all liability

or responsibility in the conduct of any such check or investigation and the disclosure of any information relating thereto. This authorization shall remain in full force

and effect until such time as actual notice of termination of such authorization is delivered in writing to the Department. A copy of this authorization shall have the

same effect as the original.

Applicant’s Authorized Signature

Date (MM/DD/YYYY)

Applicant’s Spouse’s Signature (if applicable) Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Printed Name

Form 5306 (Revised 11-2013)

Mail To:

License Offices Bureau

Phone: (573) 526-4133

P.O. Box 629

Fax: (573) 751-5327