Mississippi Representative Application by arn90681


									                                             Application for License as Representative
PLEASE TYPE OR PRINT                                                    2005
Application is hereby made for a License as indicated:
❏ Factory Representative
❏ Distributor Representative                        Social Security / License Number _______________________________________

 1. Name ___________________________________________________________________                                      Date of Birth __________________
 2. Residence Address ________________________________________________________________________________________
                                         Street                          City                  County                         State             Zip
 3. Employed By _________________________________________________________________                                        Date: __________________
                                         (Zone or District Office that supervises your activities)
 4. Address of Employer _______________________________________________________________________________________
                              Street                          County                           State               Zip        Phone
 5. Manufacturer/Distributor MMVC License# ______________________________________________________________________
 6. Date you started contacting New Motor Vehicle Dealers about New Vehicles ___________________________________________
 7. TOTAL AMOUNT OF MANUFACTURER / DISTRIBUTOR CHECK: $                                                 Date Paid                     Check Number ____
                                                                                                                   MM    DD    YY
          I hereby certify that the statements made herein are true and correct to the best of my knowledge and belief and that I am familiar with the
provisions of the laws under which this application is made.

Date ____________________________________                                       Signature    ____________________________________________
                                                                                                                Applicant’s Signature
STATE OF ______________________________ )
COUNTY OF _____________________________ )

          Subscribed and sworn to (or affirmed) before me this                  day of                     ,             .

(SEAL)                                    ___________________________________                        My Commission Expires: ____________________
                                                           Notary Public

                                                    EMPLOYER’S ENDORSEMENT
          The foregoing answers by the above applicant have been read by me and are believed to be true to the best of my knowledge and belief.
           The Applicant is recommended as trustworthy and a person who will abide by the provisions of the law and rules and regulations governing
the sale of new motor vehicles.

Date ___________________________________                                        Signed _______________________________________________
                                                                                                          Authorized Signature of Employer

                                                                                                               Name of Employer

                  Mail Completed Application and fee of $100.00 to: Mississippi Motor Vehicle Commission,
       P.O. Box 16873, Jackson, MS 39236-0873 Phone: 601-987-3995 q Fax: 601-987-3997 q E-mail: day@mmvc.state.ms.us

Revised: 11/04

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