Fillable Printable Vehicle Dealer And Automotive Mobility License Application
Fillable Printable Vehicle Dealer And Automotive Mobility License Application
Vehicle Dealer And Automotive Mobility License Application
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VEHICLE DEALER AND AUTOMOTIVE MOBILITY
LICENSE APPLICATION
State Form 56187 (R / 10-17)
Approved by State Board of Accounts, 2017
INDIANA SECRETARY OF STATE
AUTO DEALER SERVICES DIVISION
302 West Washington Street, Room E-018
Indianapolis, IN 46204
Telephone: 317-234-7190
Fax: 317-233-1915
INSTRUCTIONS: 1. Complete in blue or black ink or print completed form.
2. Submit the completed form to the Auto Dealer Services Division by mail, fax, hand delivery, or scan and e-mail using the
applicable address found in the top right corner of this form.
3. You must also submit the applicable fee under IC § 9-32-11-2(h) by mail or hand-delivery to the address found in the right top
corner of this form. A list of fees is available at http://www.in.gov/sos/dealer/4257.htm. Checks should be made payable to the
Indiana Secretary of State. The fee does not need to be submitted simultaneously with the application, but your application
cannot be processed until payment is made.
4. You must include the following with your completed application:
a. Retail Merchant Certificate
b. Proof of bond
c. Proof of liability insurance or membership in a risk retention group under IC § 9-32-11-14
d. A completed zoning affidavit as required by IC 9-32-11-2
e. If organized as a corporation, LLC, LLP, or LP, you must include your Certificate of Existence and, if applicable, Certificate
of Assumed Name. Foreign entities must include their Certificate of Authority or Registration, whichever is applicable.
5. If you indicated a, b, and/or c for Question 19, you are required to hold an automotive mobility endorsement and must include proof
of accreditation through Quality Assurance Program of the National Mobility Equipment Dealers Association with your application.
SECTION 1 - Information about your Business / Owner(s)
1. Name in which the Dealer license will be issued (DBA Name)
2. Web Address of your business
3. Business Telephone Number
( )
Alternate Telephone Number
( )
Fax Number
( )
E-mail Address
4. Address of Established Place of Business (number and street)
City
State
ZIP code
County
5. Federal identification number (FID)
6. Retail Merchant Number (TID)
Retail Merchant Location Number (LOC)
7. The established place of business location is:
Leased Owned
If leased, name of lessor
E-mail address of lessor
7a. Address of lessor (number and street)
City
State
ZIP code
Telephone number of lessor
( )
8. Type of Business Entity
Sole proprietorship Partnership Corporation LLC LLP LP
8a. Name of Business Entity (if differs from box 1)
Address (number and street)
City
State
ZIP code
8b. If corporation, LLC, LP or LLP, give date and state of incorporation / organization / registration:
Date of incorporation / organization / registration (mm/dd/yyyy): State of incorporation / organization / registration:
9. State the name and address (must be within Indiana) of the person upon whom legal services of process may be made and his/her title or relationship to applicant:
Name
Address (number and street)
City
State
IN
ZIP code
Title / Relationship to Applicant
10. Owners / Officers / Partners Who Will Appear on License (only the first three will appear on the license). Attach additional sheets, if necessary.
10a. Name of Primary Owner
Title
E-mail Address
Last 4 digits of Social Security number
XXX-XX-
Year of Birth
Address (number and street)
Contact number
( )
City
State
ZIP code
10b. Name of Owner
Title
E-mail Address
Last 4 digits of Social Security number
XXX-XX-
Year of Birth
Address (number and street)
Contact number
( )
City
State
ZIP code
10c. Name of Owner
Title
E-mail Address
Last 4 digits of Social Security number
XXX-XX-
Year of Birth
Reset Form
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Address (number and street)
Contact number
( )
City
State
ZIP code
11. Questions
11a. Has any owner, corporate officer, or partner owned or worked for another dealer in this or any other state? Yes No
11a. If yes, name of individual (individual one, if applicable)
Name of dealer
Address of dealer (number and street)
City
State
ZIP code
11a. If yes, name of individual (individual two, if applicable)
Name of dealer
Address of dealer (number and street)
City
State
ZIP code
11b. Has any owner, corporate officer, or partner on the application had a dealer license suspended or revoked or had an application for a dealer license denied in this or any
other state?
Yes No
If yes, please give details.
11c. Is this location devoted solely to the business of buying, selling and/or exchanging motor vehicles? Yes No
If no, please give details.
SECTION 2 - Information about your Dealership
12. Name of Insurance Carrier or Risk Retention Group
Policy number
Date of expiration (mm/dd/yyyy)
13. Name of bond carrier
Bond number
Date of expiration (mm/dd/yyyy)
14. Type of dealer for this application: Dealer (New) Dealer (Used)
15. Select the type(s) of vehicle(s) to be sold:
(Select all that apply.)
Type to be sold:
New / Used
Metal Dealer
Plates
requested?
Yes / No
How many plates
for this vehicle
type? (Indicate
requested amount.)
For “New”
only:
Requesting
M Plates?
Interim
Plates
requested?
Yes / No
How many plates
for this vehicle
type? (Indicate
requested amount.)
Cars
New / Used
New only Used only
Yes
No
Yes
No
Yes
No
Trucks
New / Used
New only Used only
Yes
No
Yes
No
Yes
No
Mini Trucks
New / Used
New only Used only
Yes
No
Yes
No
Yes
No
Motorcycles
New / Used
New only Used only
Yes
No
N/A
Yes
No
Motor Driven Cycle - A
New / Used
New only Used only
Yes
No
N/A
Yes
No
Motor Driven Cycle - B
New / Used
New only Used only
Yes
No
N/A
Yes
No
Mobile / Manufactured Homes
New / Used
New only Used only
Yes
No
Yes
No
Yes
No
Recreational Vehicles
New / Used
New only Used only
Yes
No
Yes
No
Yes
No
Snowmobiles / Off-road / ATV
New / Used
New only Used only
Yes
No
Yes
No
Yes
No
Trailers
New / Used
New only Used only
Yes
No
Yes
No
Yes
No
16. If selling “New”, indicate franchise(s)
17. How many units do you expect to sell during the next twelve (12) months?
Wholesale: Retail:
17a. Number of full-time sales person directly
involved with selling:
17b. Number of other full-time
employees:
18. Anticipated Hours of Operation:
Monday to
Tuesday to
Wednesday to
Thursday to
Friday to
Saturday to
Sunday to
19. Automotive Mobility Endorsement
Please indicate which, if any, applies to your business:
a. Engages exclusively in the business of selling, offering to sell, or soliciting or advertising the sale of adapted vehicles or watercraft
b. Possesses adapted vehicles or watercraft exclusively for the purpose of resale
c. Engages in the business of:
(A) selling, installing, or servicing; (B) offering to sell, install, or service; or (C) soliciting or advertising the sale, installation, or servicing of;
equipment or modifications specifically designed to facilitate use or operation of a vehicle or watercraft by an individual who is disabled.
d. None of the above apply to my business.
If you checked a, b, and/or c, you are required to hold an automotive mobility endorsement and must include proof of accreditation through Quality
Assurance Program of the National Mobility Equipment Dealers Association.
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SECTION 3 - Signature
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 Date (mm/dd/yyyy)
Printed or typed name
Title
