Form 1879 - Application For Missouri Salvage Business License
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FORM
MISSOURI DEPARTMENT OF REVENUE
Failure to do so may result in an incomplete form.
MOTOR VEHICLE BUREAU - DEALER LICENSING SECTION
1879
(573) 526-3669
APPLICATION FOR MISSOURI SALVAGE BUSINESS LICENSE
(REV. 11-2013)
IMPORTANT: Any false statement in this application is a violation of the law and may be punished by fine or imprisonment or both.
RETURN COMPLETED APPLICATION TO:
MOTOR VEHICLE BUREAU, DEALER LICENSING SECTION, P.O. BOX 43, 301 WEST HIGH, ROOM 370, JEFFERSON CITY, MISSOURI 65105.
3. FEES
1. BUSINESS NAME
STREET (PHYSICAL ADDRESS)
TELEPHONE
(__ __ __) __ __ __ - __ __ __ __
LICENSURE FEES
$
CITY
STATE
ZIP CODE
COUNTY
__ __ __ __ __ - __ __ __ __
BACKGROUND
COMPLETE IF MAIL TO ADDRESS IS DIFFERENT THAN ABOVE (REQUIRES LETTER FROM POSTAL AUTHORITY)
2. BUSINESS NAME
CHECK FEES
$
STREET
CITY
STATE
ZIP CODE
TOTAL
$
__ __
__ __ __ __ __ - __ __ __ __
4. MO RETAIL SALES TAX NUMBER:
5. LICENSE EXPIRATION YEAR:
6. NUMBER OF SALVAGE ID CARDS REQUESTED (ONLY ISSUED TO
SALVAGE DEALERS OR DISMANTLERS)
EXEMPT:
YES
NO
_____ _____ _____ _____
7. APPLICATION FOR A LICENSE TO ENGAGE IN THE BUSINESS OF: (SELECT ALL THAT APPLY) SEE DEFINITIONS ON REVERSE.
A. USED PARTS DEALER
B. SALVAGE DEALER OR DISMANTLER
(IN ORDER TO BE TAX EXEMPT ON THE PURCHASE OF MOTOR VEHICLES YOU MUST ALSO BE LICENSED AS A MOTOR VEHICLE DEALER
.)
C. BODY SHOP OR REBUILDER
D. SCRAP PROCESSOR
8. DO YOU CONDUCT A SALVAGE BUSINESS AT ANY LOCATION OTHER THAN THE ADDRESS SHOWN ABOVE?
YES
NO
IF YES, PROVIDE THE FOLLOWING DETAILS: (ATTACH A SEPARATE SHEET IF NECESSARY.)
BUSINESS NAME
LICENSE NUMBER
STREET
CITY
STATE
ZIP CODE
__ __
__ __ __ __ __ - __ __ __ __
IF YOU HAVE PURCHASED A PREVIOUSLY REGISTERED SALVAGE BUSINESS WITHIN THE PAST REGISTRATION PERIOD, INDICATE THE SALVAGE BUSINESS NUMBER
9. HAVE YOU EVER BEEN REGISTERED BEFORE AS A MISSOURI SALVAGE BUSINESS?
YES
NO
IF YES, PROVIDE THE FOLLOWING DETAILS: (ATTACH A SEPARATE SHEET IF NECESSARY.)
PRIOR SALVAGE BUSINESS NAME
PRIOR LICENSE NUMBER
CITY
LAST YEAR LICENSED
10. HAS YOUR SALVAGE BUSINESS LICENSE EVER BEEN DENIED, SUSPENDED OR REVOKED?
YES
NO
IF YES, GIVE DETAILS AND FULL EXPLANATION ON A SEPARATE SHEET.
11. ARE YOU CURRENTLY A REGISTERED MOTOR VEHICLE, BOAT, OR TRAILER DEALER?
YES
NO
IF YES, GIVE DEALER NUMBER
D___________________________________
12. TYPE OF OWNERSHIP
1. INDIVIDUAL
2. PARTNERSHIP
3. CORPORATION. (STATE OF INCORPORATION): _____ _____
4. LIMITED PARTNERSHIP
5. LIMITED LIABILITY CORPORATION
13. LIST ALL OWNERS BELOW: (ATTACH A SEPARATE SHEET FOR ADDITIONAL OWNERS.)
SOCIAL SECURITY
LAST NAME
FIRST
M. INITIAL
BIRTHDATE
HOME TELEPHONE
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
NUMBER
1.
__ __ __ __ __ __ __
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ / __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
2.
__ __ __ __ __ __ __
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ / __ __ __ __ ( __ __ __ ) __ __ __ - __ __ __ __
3.
__ __ __ __ __ __ __
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ / __ __ __ __ ( __ __ __ ) __ __ __ - __ __ __ __
4.
__ __ __ __ __ __ __
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ / __ __ __ __ ( __ __ __ ) __ __ __ - __ __ __ __
14. HAVE ANY OF THE PERSONS OR ENTITIES NAMED HEREIN EVER BEEN CONVICTED OF A FELONY?
YES
NO
IF YES, ENTER PERSON’S NAME AND DATE OF CONVICTION(S) BELOW. (USE A SEPARATE SHEET IF NECESSARY.)
NAME
DATE
NAME
DATE
__ __ /__ __/ __ __ __ __
__ __ /__ __/ __ __ __ __
I DO SOLEMNLY AFFIRM THAT I MAINTAIN A BONA FIDE ESTABLISHED PLACE OF BUSINESS AS DEFINED BY SECTION 301.221, RSMo, AT THE ADDRESS SHOWN ABOVE TO CONDUCT THE BUSINESS
INDICATED. I FURTHER RESOLVE THAT THE STATEMENTS CONTAINED HEREIN AND ON ANY ATTACHMENTS HERETO ARE TRUE AND THAT I HAVE AUTHORITY TO SIGN THIS APPLICATION. ANY FALSE
OR ERRONEOUS INFORMATION PROVIDED WILL CAUSE DENIAL, SUSPENSION, OR REVOCATION OF ANY SALVAGE LICENSE THAT WAS FRAUDULENTLY OBTAINED OR ERRONEOUSLY ISSUED.
15. SIGNATURE OF AN OWNER, PARTNER,
DATE
__ __ /__ __/ __ __ __ __
OR CORPORATE OFFICER REQUIRED.
16. 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 USED PARTS DEALER, SALVAGE DEALER AND DISMANTLER, BODY SHOP OR REBUILDER, OR SCRAP PROCESSOR AS DEFINED IN SECTIONS 301.010 AND 301.218 RSMo.
DATE APPROVED
NAME AND RANK
DEPARTMENT/TROOP/DISTRICT
BADGE NO.
DATE DISAPPROVED
NAME AND RANK
DEPARTMENT/TROOP/DISTRICT
BADGE NO.
REASON FOR DISAPPROVAL
DEPARTMENT USE ONLY
REJECTED BY:
APPROVED BY:
DATE APPROVED:
DOR-1879 (11-2013)
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