Fillable Printable Dealer License Application Used Partsand Scrap Metal
Fillable Printable Dealer License Application Used Partsand Scrap Metal
Dealer License Application Used Partsand Scrap Metal
Notice: By signing this application, each applicant certifies that all information is true and correct and that the applicant meets the
qualifications outlined in Minnesota Statutes, section 168.27. If any information is untrue, it may be the basis for denial of a dealer license
or revocation of an existing dealer license. Statutory requirements for the collection of information: Minnesota Statutes, sections 168.27,
270C.72, and 299A.01, Minnesota Rules, part 7400.0300 and 7400.0200. With the exception of driver's license numbers and social
security numbers, all information provided on this form is public.
USED VEHICLE PARTS/SCRAP METAL LICENSE APPLICATION
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
OFFICE USE ONLY
INITIALS:
AREA:
COUNTY:
DATE RECEIVED:
DEALER NUMBER:
• Complete both sides of form
• Return form and license fees (check or money order payable to DVS) to the address above
• Complete Certification of Minnesota Worker's Compensation Laws Form (PS2420)
PLEASE CHECK THE TYPE OF LICENSE YOU ARE APPLYING FOR:
Used Vehicle Parts Scrap Metal Processor
LICENSE FEES: $250
COMPANY NAME:
MN Tax ID Number:
List all the assumed names (DBA) under which you will be conducting dealer business:
1.)
2.)
3.)
Type of Company Ownership - Check One:
Hours of Operation:
Hours Records Available for Inspection:
Individual Partnership Corporation LLC
COMMERCIAL ADDRESS REQUIRED: Attach a separate sheet to file additional locations.
Street Address
State Zip
City
Business Phone Number
Business Fax
Business Email
County
- over -
445 Minnesota Street, St. Paul, MN 55101-5186
Phone: (651) 201-7800 Fax: (651) 297-1480
Web: dvs.dps.mn.gov Email: [email protected]
DRIVER AND VEHICLE SERVICES
PS2406-15 (05/16)
1. Are the books, records and files necessary to conduct business kept and maintained at the above address?
If you answered No, please explain:
Yes No
2. Is personnel available or an automatic telephone service available during normal business hours?
NoYes
If you answered No, please explain:
Print Form
List the names of all owners, officers, board members, governors, and five percent and greater shareholders. Company names are not
acceptable. If you require more room, please provide information on a separate sheet and attach to this application.
DEALER OWNERSHIP INFORMATION - Please Print
Each person named on this application must sign.
1.
X
Subscribed and sworn to before me this
day of _______ 20 _____
NOTARY PUBLIC
COUNTY:
MY COMISSION EXPIRES:
Subscribed and sworn to before me this
day of _______ 20 _____
NOTARY PUBLIC
COUNTY:
MY COMISSION EXPIRES:
Subscribed and sworn to before me this
day of _______ 20 _____
NOTARY PUBLIC
COUNTY:
MY COMISSION EXPIRES:
2.
X
3.
X
DEALER OWNERSHIP HISTORY
If you answer yes to questions one and two, please attach a separate statement to this application that includes the name of the person
convicted, date of conviction, and state and county where the conviction took place.
1. Has anyone named on this application been enjoined or convicted of violating any of the following within the last ten years:
• Consumer Fraud in Sales - Minnesota Statutes, section 325F.69
• Odometer Tampering - Minnesota Statutes, sections 325E.14, 15, 16, or United States Code, title 15
• Receiving or Selling Stolen Vehicles - Minnesota Statutes, section 609.53
Yes No
2. Has anyone named on this application pleaded guilty, entered a plea of nolo contendere or no contest, or been found guilty
in a court of competent jurisdiction of any charge of failure to pay state or federal income or sales taxes, or felony charge of
forgery, embezzlement, obtaining money under false pretenses, theft by swindle, extortion, conspiracy to defraud, or
bribery within the last ten years?
Yes
No
3. Has anyone named on this application applied for or held a Minnesota dealer's license in the past?
Yes
No
Name of person who applied for or held license:
Name of dealership and license number:
When was the dealership last licensed:
Was the license ever canceled, denied, suspended, or revoked?
Yes (explain below) No
1.) Full Name:
Date of Birth (mm/dd/yyyy)
Driver's License Number:
State:
Position with Dealership:
2.) Full Name:
Date of Birth (mm/dd/yyyy)
Driver's License Number:
State:
Position with Dealership:
3.) Full Name:
Date of Birth (mm/dd/yyyy)
Driver's License Number:
State:
Position with Dealership:
PS2406-15 (05/16)
Social Security Number:
Social Security Number:
Social Security Number:
