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Fillable Printable Form 1879 - Missouri Department Of Revenue

Fillable Printable Form 1879 - Missouri Department Of Revenue

Form 1879 - Missouri Department Of Revenue

Form 1879 - Missouri Department Of Revenue

Do you conduct a salvage business at any location other than the address shown above? r Yes r No
If yes, provide the following details: (attach a separate sheet if necessary.)
Business Name License Number
Street Address City State Zip Code +4
If you have purchased a previously registered salvage business within the past registration period, indicate the salvage business number.
Have you ever been registered before as a Missouri salvage business?
r Yes r No If yes, provide the following details: (attach a separate sheet if necessary.)
Prior Salvage Business Name Prior License Number City Last Year Licensed
Has your salvage business license ever been denied, suspended or revoked?
r Yes r No If yes, give details and full explanation on a separate sheet.
Are you currently a registered motor vehicle, boat, or trailer dealer?
r Yes r No If yes, give dealer number. D___________________________________
r Individual r Partnership r Corporation. (State of Incorporation): _____ _____ r Limited Partnership r Limited Liability Corporation
List all owners below: (attach a separate sheet for additional owners.)
Last Name First Name Middle Initial Social Security Number Birthdate (MM/DD/YYYY)
Telephone Number Residence Address City State ZIP Code + 4
Last Name First Name Middle Initial Social Security Number Birthdate (MM/DD/YYYY)
Telephone Number Residence Address City State ZIP Code + 4
Last Name First Name Middle Initial Social Security Number Birthdate (MM/DD/YYYY)
Telephone Number Residence Address City State ZIP Code + 4
Have any of the persons or entities named herein ever been convicted of a felony?
r Yes r No
If yes, enter person’s name and date of conviction(s) below. (Use a separate sheet if necessary.)
Name Date (MM/DD/YYYY) Name Date (MM/DD/YYYY)
Business Name DBA Name Person to Contact
Street Address (Physical Address) City State Zip Code +4
Missouri Secretary of State Registration Number (if applicable) Telephone Number County
Complete if mail to address is different than above (requires letter from postal authority).
Business Name
Street Address City State Zip Code +4
Form
1879
Missouri Department of Revenue
Application for Missouri Salvage
Business License
Visit https://mydmv.mo.gov/ to renew or apply online.
Any false statement in this application is a violation of the law and may be punished by ne or imprisonment or both.
Business Information
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Fees
Exempt: r Yes r No
Type
r Used Parts Dealer r Body Shop or Rebuilder r Scrap Processor
r Salvage Dealer or Dismantler (In order to be tax exempt on the purchase of motor vehicles you must also be licensed as a motor vehicle dealer.)
Current and Past Salvage History
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Ownership Information
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Licensure Fees Total Missouri Retail Sales Tax Number
Application for a license to engage in the business of: (Select all that apply) See Missouri Titling Manual for definitions
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A signature of an owner, partner, or corporate ofcer required.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I do solemnly affirm that I maintain a
bona fide established place of business as defined by Section 301.221, RSMo, at the address shown above to conduct the business indicated. I further resolve
that the statements contained herein and on any attachments hereto are true and that I have authority to sign this application. Any false or erroneous information
provided will cause denial, suspension, or revocation of any salvage license that was fraudulently obtained or erroneously issued.
Signature Title
Printed Name Date (MM/DD/YYYY)
Complete each area on the application and submit with the appropriate fees to the address listed below. All illegible, incorrect, or incomplete
applications will be rejected. For more information visit our website at: http://dor.mo.gov/forms/Missouri_Titling_Manual.pdf
Business Information
• The complete salvage business name and address must be shown. A post office box number without a street address will not be accepted
as an actual business address.
• Complete the business name and mail to address if necessary. You must include a letter from the local postal authorities stating they cannot
or will not deliver mail to the actual business location.
Fees
• Submit required fees as outlined in the Missouri Titling Manual.
License Type
• Indicate the type of license needed, see Missouri Titling Manual for definitions of license types.
Current and Past Salvage History
• Complete all areas of the current and past salvage history section.
Ownership Information
• Indicate the type of ownership of the business.
• List each owner, partner, and corporate or company officer of the business.
• You must list the Social Security Number, date of birth, and address of all owners. Telephone number is optional.
• Every owner, partner, or principal officer must obtain a “name based” criminal record from the Missouri State Highway Patrol.
Visit https://www.machs.mshp.dps.mo.gov to obtain name based criminal records online. An owner, partner, or principal officer residing
in another state must obtain a criminal record from the state of his or her residence. All required criminal records must be submitted with
your dealer license application.
Signature
• The application must be signed by a business owner, partner, or principal officer.
Inspection and Certification
• An authorized law enforcement officer or designee must complete this section. Dealers selling only emergency vehicles are exempt from
this requirement. If the business is located in a first class county (Boone, Buchanan, Camden, Callaway, Cape Girardeau, Cass, Clay, Cole,
Franklin, Greene, Jackson, Jasper, Jefferson, Platte, St. Charles, St. Louis, St. Louis City, and Taney), an authorized city policeman who is
employed in the same city the business is located may complete the inspection. Certifications may not be completed by a sheriff or marshal.
(Reference Sections 301.550 through 301.573 RSMo).
Required documents to include with application
r Criminal records for each owner, partner, or principal officer
r Current photograph of the bona fide place of business; include the building, lot, and sign. If it is a temporary sign, include a photograph of the
temporary sign and the work order for the permanent sign.
r If applying as a used parts dealer, a copy of the applicant’s Missouri Retail Sales Tax License must be submitted. If applying as a salvage
dealer and dismantler, either a copy of the applicant’s Missouri Retail Sales Tax License, or a statement signed by the owner, confirming the
business sells parts on a wholesa le basis only must be submitted.
r One check or money order made payable to the Missouri Department of Revenue if applied by mail.
NOTE: The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds.
See instructions for who must complete this section.
I certify that I have physically inspected the above location and that the applicant’s business qualies as a bona de used parts dealer, salvage dealer and dismantler, body
shop or rebuilder, or scrap processor as dened in Sections 301.010 and 301.218 RSMo.
Date Approved (MM/DD/YYYY) Name and Rank Department, Troop, and District Badge Number
Date Disapproved (MM/DD/YYYY) Name and Rank Department, Troop, and District Badge Number
Reason for Disapproval
Signature
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Inspection and Certification
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Important Instructions to Applicant
Mail to: Motor Vehicle Bureau Phone: (573) 526-3669 Opt. 7
Dealer Licensing Section Fax: (573) 522-4197
PO Box 43 TTY: (800) 735-2966
301 West High Street, Room 370 E-mail: [email protected]
Jefferson City, MO 65105-0043
Visit http://dor.mo.gov/
for additional information.
Form 1879 (Revised 12-2017)
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