Motor Vehicle Salvage Dealer Application {BMV 4363}

OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES MOTOR VEHICLE SALVAGE DEALER, SALVAGE MOTOR VEHICLE AUCTION, SALVAGE MOTOR VEHICLE POOL APPLICATION BMV USE ONLY: YES NO Are you or your spouse a veteran or member of the armed forces or a surviving spouse of a veteran or member of the armed forces? (NOTE: a completed application with the required documentation of military status qualifies the applicant for an expedited application process, upon receipt.) If "yes", please provide a copy of you or your spouse's DD214, an official military ID for verification, separation documentation, or other official military documentation approved by the board. INITIAL Note: The issuance of a Motor Vehicle Salvage Dealer's License, Salvage Motor Vehicle Auction or Salvage Motor Vehicle Pool does not supersede local zoning. The State of Ohio (BMV) Dealer Licensing Section is the regulator of motor vehicle dealers, but does not pre-empt the enforcement by local authorities of zoning, health, safety codes, or laws. It is recommended that each applicant check zoning regulations applicable to the proposed facility with their local authority prior to making application. I affirm that I have completed the I-9 Employment Eligibility Verification form that is required to be on file with the employer under the Immigration Reform and Control Act of 1986, 8 USC 1324a (with the exception of sole proprietors). INITIAL INDICATE SALVAGE LICENSE TYPE (check ONLY one) *Motor Vehicle Salvage Dealers License For salvage license that deals primarily in motor vehicle parts. *Salvage Motor Vehicle Auction For salvage license that engages in the business of auctioning salvage motor vehicles to authorized purchasers. Motorcycle / Motor Scooter / APV Salvage Dealers For salvage license that deals exclusively in motorcycles / motor scooters / APV's parts. (NOTE: If any motor vehicle parts will be sold, you must apply for a Salvage Motor Vehicle Dealers License and meet the requirements.) *Salvage Motor Vehicle Pool For salvage license that engages in the business of storing, displaying, and offering for sale, salvage motor vehicles to authorized purchasers. SALVAGE DEALER, SALVAGE AUCTION, OR SALVAGE POOL INFORMATION EXACT BUSINESS NAME REGISTERED DBA OR TRADE NAME BUSINESS STREET ADDRESS CITY BUSINESS PHONE # FAX # E-MAIL ADDRESS STATE ZIP CODE ALTERNATE PHONE # COUNTY FEDERAL TAX ID OR EIN # VENDOR'S # REGISTERED DBA OR TRADE NAME HOURS OF OPERATION OPEN CLOSE OPEN CLOSE OPEN CLOSE SUNDAY MONDAY TUESDAY BMV 4363 12/15 [17601163] Page 1 of 6 WEDNESDAY THURSDAY FRIDAY SATURDAY American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS ENTITY INFORMATION (Mark one and complete ownership information) Sole Proprietor Partnership (Partners) Corporation (President, Vice President, Treasurer, Secretary) Business Trust (Trustee) Other Registered Entity* Limited Liability (Members) *Must include a copy of the registered business entity that has been filed with the Secretary of State. You may be required to show the registered ownership structure. NOTE: If a Member of a LLC is a corporation first list the corporation's name, federal tax ID number, address and then list the officer's name, address and social security number of the applicant. If a Partner of a partnership is a corporation first list the corporation's name, federal tax ID number, address and then list the officer's name, address and social security number of the applicant. If a Trustee of a business trust is a corporation first list the corporation's name, federal tax ID number, address and then list the officer's name, address and social security number of the applicant. NOTE: Ohio residents who are owners, partners, president, members owning 10% or more, trustees or principal owners of any "other registered entity" ownership style MUST be electronically fingerprinted and applicants must request the results be sent electronically to direct copy "BMV Dealer Licensing" at the web check locations in order for them to be forwarded to the BMV Dealer Licensing Section. (For a complete list of electronic fingerprinting locations in Ohio visit www.ohioattorneygeneral.gov.) NOTE: Out-of-state applicants or those who qualify for electronic exemption must submit a fingerprint card, exemption form, and fingerprint card processing fee with the application for license. Call the Dealer Licensing Section at (614) 752-7636 to obtain a fingerprint card and exemption form. NOTE: Applications for a motor vehicle salvage dealer, salvage motor vehicle auction or salvage motor vehicle pool license shall be denied for reasons listed in the Ohio Revised Code (R.C.) 4738.07 which include: Conviction of a crime of moral turpitude or disqualifying offense as defined in R.C. 4776.10. Conviction of ANY misdemeanor or felony (regardless of the conviction date) related to dealing in salvage motor vehicles. NOTE: Applications for a motor vehicle salvage dealer, salvage motor vehicle auction or salvage motor vehicle pool license may be denied for reasons listed in the R.C. 4738.07 which include: Conviction of a felony that is not a crime of moral turpitude or a disqualifying offense less than three years prior to application. Conviction of a misdemeanor that is not a crime of moral turpitude or a disqualifying offense less than one year prior to application. OWNERSHIP INFORMATION FAILURE TO COMPLETE ANY PORTION WILL DELAY THE PROCESSING OF THIS APPLICATION APPLICANT NAME OR CORPORATION NAME HOME OR CORPORATION ADDRESS CITY, STATE, ZIP TELEPHONE # TITLE SSN / FEIN OWNERSHIP % (if member) ELECTRONIC FINGERPRINTS COMPLETED? YES NO NOT APPLICABLE DATE COMPLETED APPLICANT NAME (first, middle, last, suffix) HOME ADDRESS CITY, STATE, ZIP TELEPHONE # TITLE SSN OWNERSHIP % (if member) ELECTRONIC FINGERPRINTS COMPLETED? YES NO NOT APPLICABLE DATE COMPLETED BMV 4363 12/15 [17601163] Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT NAME (first, middle, last, suffix) HOME ADDRESS CITY, STATE, ZIP TELEPHONE # TITLE SSN OWNERSHIP % (if member) ELECTRONIC FINGERPRINTS COMPLETED? YES NO NOT APPLICABLE DATE COMPLETED APPLICANT NAME (first, middle, last, suffix) HOME ADDRESS CITY, STATE, ZIP TELEPHONE # TITLE SSN OWNERSHIP % (if member) ELECTRONIC FINGERPRINTS COMPLETED? YES NO NOT APPLICABLE DATE COMPLETED Any additional persons please list on a separate sheet of paper and attach to this application. Provisional Motor Vehicle Salvage License: It is understood that a physical inspection will