Form Dsd 10 - Manufacturer And Distributor License Application For Initial License Or Renewal

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MANUFACTURER AND DISTRIBUTOR

DSD 10 (07/28/2017)

OFFICE USE ONLY

LICENSE APPLICATION

P.C.T. & O. FEE

SLS FEE

FOR INITIAL LICENSE OR RENEWAL

AMT. OF CHECK

TOTAL FEE

FOR LICENSE YEAR ENDING

OVERPAY

CHECK NO.

RETURN OVERPAY

ASMT. FEE

FOR APPROVAL

CLERK'S

PURPOSE:

Manufacturers, distributors and factory branches use this form to apply for, renew or change a license to

INITIALS

do business in the Commonwealth.

Each applicant must include a sample franchise agreement if doing business with more than one dealer (see Franchise Agreement Information on page 2). If

applicant does not do business with more than one dealer, he/she may choose not to submit a sample franchise agreement but must include a statement

acknowledging the applicant’s understanding that he/she must provide a sample franchise agreement upon doing business with more than one dealer.

Each distributor must include a copy of a distributor agreement with, or a parent letter from, the manufacturer or parent distributor authorizing the distribution of

each vehicle line-make listed on the application.

APPLICATION TYPE

Authorized Changes: address change, name change, add/delete manufacturer or distributor, ownership change and relocation.

CHANGE

INITIAL APPLICATION

RENEWAL APPLICATION

(explain)

VEHICLE/BUSINESS TYPE

Vehicle Type

CAR / TRUCK / UTILITY

MOTORCYCLE

TRAILER

RECREATIONAL VEHICLE

Business Type

MANUFACTURER - a person engaged in the business of constructing or assembling new motor vehicles and, in the case of trucks, also means a person

engaged in the business of manufacturing engines, transmissions, power trains, or rear axles, when such engines, transmissions, power trains or rear axles

are not warranted by the final manufacturer or assembler of the truck.

DISTRIBUTOR - a person who sells or distributes new motor vehicles pursuant to a written agreement with the manufacturer, to franchised motor vehicle

dealers in the Commonwealth.

FACTORY/DISTRIBUTOR BRANCH - a branch office maintained by a person for the sale of motor vehicles to distributors or for sale of motor vehicles to

motor vehicle dealers, or for directing or supervising, in whole or in part, its representatives in the Commonwealth.

BUSINESS INFORMATION

BUSINESS NAME

TRADING AS NAME

LICENSE NUMBER

BUSINESS STREET ADDRESS

CITY

STATE