Form D-16 - Application For Title Service Agent

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KANSAS
APPLICATION FOR
DEPARTMENT OF REVENUE
TITLE SERVICE AGENT
DIVISION OF VEHICLE
$75.00
ALL Information REQUIRED.
TOTAL FEE DUE:
Must Type or Print Clearly
FEE IS NOT PRORATED
B
I
USINESS
NFORMATION
Name of Business
Doing Business As” (dba) Name
Business Address
City
County
State
ZIP
Business Phone
Fax
If Applicable
Cell Phone
email address
If Applicable
If Applicable
Sales Tax Number: 004-
- F
FEIN Number
If Applicable
(9 digit number)
(2 digits)
Check box which indicates the type of business (entity):
Individual
Partnership
Corporation*
Limited Liability Company*
LTD Company*
Limited Liability Partnership*
Date Incorporated/Registered & State
* Copy and attach the Secretary of State’s registration papers to this application. (Required)
O
I
WNER
NFORMATION
Please provide the information below for each owner(s) of the business.
NOTE: When a corporation is owned by more than 20 stockholders, such corporation may list the President, Vice-
President, Secretary and Treasurer of the corporation in lieu of listing the stockholders.
T
B
O
/C
O
I
I
REQUIRED.
HE
ELOW
WNER
ORPORATE
FFICER
NFORMATION
S
P
P
T
A
I
LEASE
RINT OR
YPE
LL
NFORMATION
Complete Legal Name
Residence Address
Residence
Date of Birth
SSN
Sex
Phone

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