APPLICATION FOR DEALER BUSINESS LICENSE
State Form 13215 (R9 / 8-09)
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SECRETARY OF STATE - DEALER DIVISION 302 W. Washington Street, Room E018 Indianapolis, Indiana 46204-2700 Telephone: (317) 234-7190 Fax: (317) 233-1915
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
INSTRUCTIONS:
1. 2. 3. 4.
Include a copy of the certificate of liability insurance or SR23 with this application. If applying for a new dealer license, please provide a copy of the franchise agreement. If applicant is a corporation, limited liability company (LLC), or a limited liability partnership (LLP), please provide documentation. Include a copy of State Form 53966, Indiana Vehicle Merchandising Certificate / Bond.
2. Federal identification number (FIN) Fax number E-mail address ZIP code County ZIP code County Tax identification number City Township City Township Line of credit number (on RRMC)
1. Name in which the business license will be issued 3. Daytime telephone number Evening telephone number
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4. Legal address of business (number and street) State 5. Mailing address (number and street) State 6. Registered retail merchant's certificate (RRMC) number 7. The business location is:
If leased, name of lessor
Leased
Owned
Telephone number of lessor
Address of lessor (number and street, city, state, and ZIP code) 8. Name of insurance carrier Policy number
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Date of expiration (month, day, year)
9. Indicate the type of license being applied for by checking the appropriate box.
Dealer Dealer Branch Manufacturer
Factory Branch Factory Representative
Distributor Distributor Branch Distributor Representative
Automobile Auction Automobile Auction Branch
Dealer number
Wholesale Dealer Transfer Dealer Converter Manufacturer
10. If applying for a branch location, name of dealership 11. If applying for a DEALER LICENSE, indicate the type of vehicles sold by checking the appropriate box(es). CARS TRUCKS MOTORCYCLES MOBILE HOMES
RECREATIONAL VEHICLES
OTHER
New Only Used Only New & Used
New Only Used Only New & Used
New Only Used Only New & Used
New Only Used Only New & Used
New Only Used Only New & Used
New Only Used Only New & Used
If you checked Other, please explain. 12. Number of full-time sales persons directly involved with selling 15. Type of applicant (check one) 13. Number of other full-time employees 14. How many vehicles do you expect to sell during the next twelve months?
Wholesale ____________ b. Partnership c. Corporation Yes No d. LLC
Retail ____________ e. LLP
a. Sole proprietorship
16. Do you intend to buy dealer plates?
17. Do you intend to buy interim plates?
Yes
No
How many? ____________
How many? ____________
18. ZONING APPROVAL - TO BE COMPLETED BY LOCAL ZONING BOARD / AUTHORITY I, the undersigned, verify compliance with local zoning ordinances or other local ordinances for conducting motor vehicle business at the address cited above.
Signature Printed or typed name Authorizing agency Title Date (month, day, year)
Page 1 of 2
19. OWNER INFORMATION
Name of primary owner Home address (number and street) City Name of additional owner Home address (number and street) City Name of additional owner Home address (number and street) City State State Title State Title Title Social Security Number * ZIP code Home telephone number
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Social Security Number * ZIP code
Home telephone number
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Social Security Number * ZIP code
Home telephone number
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Yes No
Has any owner, partner, officer, or director of the applicant owned or worked for another dealer in this or any other state in the last three (3) years? If yes, name of individual Address of dealership (number and street, city, state, and ZIP code) If yes, name of individual Address of dealership (number and street, city, state, and ZIP code) 20. Name of person upon whom legal service or process may be made 21. If corporation, LLC, or LLP, state of action NAME OF EMPLOYEE Address (number and street, city, state, and ZIP code) If foreign corporation (not Indiana), date of admission to do business in Indiana (month, day, year) STATE TELEPHONE NUMBER SOCIAL SECURITY NUMBER * Name of dealership Name of dealership
Date of action (month, day, year)
ADDRESS (number and street, city)
22. QUESTIONS
Has any owner, partner, officer, director, or agent of the applicant had a civil judgment or criminal conviction against them for any State or Federal laws concerning the sale, distribution, financing, or insuring of motor vehicles within the last three (3) years? If yes, please give details. Has any owner, partner, officer, director, or agent of the applicant had dealer plates suspended or revoked or had an application for dealer plates rejected on this or any other state within the last three (3) years? If yes, please explain. Is this location devoted solely to the business of buying, selling, and/or exchanging motor vehicles? If no, please explain.
Yes
No
Yes
No
Yes
No
PLEASE NOTE:
Every dealer, manufacturer, distributor, factory branch, or distributor branch must file with the Secretary of State a current copy of each franchise to which it is a party; or, if multiple franchises are identical except for stated items, a copy of the franchise form with supplemental schedules of variations from the form is acceptable. All books, records, and files relating to the applicantÂ’s inventory and motor vehicle titles must be kept at the established place of business and be available for inspection.
I hereby certify, under the penalty of perjury, that I am authorized to make this application and that the answers and information contained in this application are true and correct.
Signature of applicant Printed or typed name Title Page 2 of 2 Date (month, day, year)