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. N „ <br /> MINNESOTA DEPARTMENT OF PUBLIC SAFETY OFFICE USE ONLY <br /> DRIVER AND VEHICLE SERVICES DEALER NUMBER: <br /> 445 Minnesota Street, Suite 186, St. Paul, MN 55101-5186 DATE RECEIVED:. <br /> ' P� HONE:651-296-2977 COUNTY: <br /> FAX:651-297-1480 <br /> EMAIL:DealerQuestion@mnddveinfo.org AREA: <br /> INITIALS: <br /> Motor Vehicle Dealer License Application <br /> • Complete both sides of this form <br /> • Return form and license fees(check or money order payable to DVS)to the address above <br /> • The following must accompany your application for a dealer license: Commercial Vehicle Checklist(PS2407), Zoning <br /> Verification (PS2421), Certification of Compliance with Minnesota Worker's Compensation Law(PS2420), Dealer <br /> Surety Bond(PS2446), DemonstrationAn-Transit Plate application (PS2405), Franchise Agreement if applicable <br /> (PS2404),Verification of Property Lease(PS2407)or proof of building ownership. <br /> Notice <br /> By signing this application, each applicant certifies that all information.,is true and correct and that the applicant meets the <br /> qualifications outlined in Minnesota Statutes, section 168.27. If any information is untrue, it may be the basis for denial of a . <br /> dealer license or revocation of an existing dealer license. <br /> Statutory requirements for the collection of'information: Minnesota Statutes, sections 168.27,270.72, and 299A.01, Minnesota <br /> Rules, part 7400.0300 and 7400.0200. <br /> With the exception of driver's license numbers and social security numbers, all information provided on this form is public. <br /> PLEASE CHECK THE TYPE OF LICENSE YOU ARE APPLYING FOR: <br /> ❑NEW ASED QILESSOR E/WWHOLESALER BROKER AUCTIONEER ❑SALVAGE POOL ❑LIMITED USE VEHCILE ❑DSB . <br /> LICENSE FEES: .DSB License$18.50 All Other Dealer Licenses-$258.50 <br /> DEALER NAME MN Tax ID Number -+.�L-- <br /> List all assumed names(DBA)under which you will be conducting dealer business: <br /> 1.) <br /> 2.) <br /> 3.) <br /> Type of Company Ownership—Check One: ❑Individual ❑Partnership ❑Corporation ❑LLC <br /> All <br /> Hours of Operation: Q AM <br /> Hours Records Available for Inspe 'on: �m nn <br /> Mit 1\,�fo. <br /> DEALER ADDRESS -Attach a separate sheet to file additional locations within the same county. If the location is in another county,a <br /> separate license for that location is required. <br /> trbetV <br /> Crt�r" t1� ty State Zip 1 County 9PI14PJOIYU <br /> ;E3 n ssgogeN,umbq Business FAX:( 0�. �q�- �a93 Email:wIGQ671�I <br /> LIA81L)TY INS1J42At� fi FORMATION <br /> Insurance Company Name: <br /> Pol ey-,Nwmbeg. <br /> Insurance-Agent's N Phone:L_) <br />