Free AR-0069 Dealer Corporation Officer Change Application - Michigan

Dear Vehicle Dealer: You recently requested an application to file a change of owner, partner, or officer for your dealer license, or we have determined that such a change has occurred. You must submit the following, as applicable to your situation: 1. Dealer Corporation Officer Change Application. Please complete all items. Note: Item 6 must list all current owners, partners, or officers, including new applicants. Item 9 must be signed by all current owners, partners, or officers, including new applicants. Items 7 and 8 must be completed for each new applicant. 2. Rider for Vehicle Dealer Surety Bond (applies only to partnerships and to individual ownerships when adding a spouse). A bond rider listing all current owners or partners and showing the correct assumed name (d/b/a) and business address must be submitted.

3. New assumed name filing (applies only to partnerships and individual ownerships when adding a spouse). A new assumed name or d/b/a filing listing all current owners or partners and showing the correct business address must be submitted. The assumed name filing must be obtained from the County Clerk for the county in which your dealership is located. 4. Each new applicant listed in Item 6 on the application must be fingerprinted. A private vendor, L-1 Identity Solutions, performs this service. Fingerprints are taken by appointment only. You can schedule an appointment by contacting L-1 Identity Solutions directly at 1-866-226-2952 or online at www.mi.ibtfingerprint.com. Take the Live Scan Fingerprint Request included in this packet to that appointment. L-1 Identity Solutions will collect all fees associated with fingerprinting. They will provide you with a signed receipt as proof of fingerprinting. Please include a copy of that signed receipt when you submit your completed Dealer Corporate Officer Change Application. Please complete the application carefully and return with the L-1 Identity Solutions receipt, the bond rider and assumed name filing, if applicable. Please remember that the owners/partners names, business name and business address must be exactly the same on the application, bond rider and assumed name filing. RETURN TO: Michigan Department of State Licensing Unit Lansing, MI 48918 Please contact the Licensing Unit at 1-888-SOS-MICH (1-888-767-6424), if you have any questions regarding the application or related items. Enclosures 05/2008

AR-0069 (10/06) by Authority of PA 300 of 1949, as amended Michigan Department of State 1-888-SOS-MICH (1-888-767-6424)

DEPARTMENT USE ONLY License Number

Clear Form

DEALER CORPORATE OFFICER CHANGE APPLICATION
READ CAREFULLY BEFORE TYPING OR PRINTING
1. 3. BUSINESS NAME (Include any assumed name or corporate name) BUSINESS TYPE (Check only one) Individual Owner (one person or husband & wife) Partnership (two or more people or husband & wife) BUSINESS LOCATION
(Street)

Approved By

Date

2. 4. Corporation Limited Liability Company

DEALER NUMBER BUSINESS TELEPHONE ( )
(County)

5.

(City)

(Zip)

6.

OWNERS, PARTNERS, CORPORATE OFFICERS AND DIRECTORS List information for ALL OWNERS, PARTNERS, CORPORATE OFFICERS AND DIRECTORS. For corporations, "owners" includes any stockholder holding 25% or more of the stock issued. Limited liability companies must include information for ALL MEMBERS AND MANAGERS. ALL NEW PERSONS LISTED ARE CONSIDERED NEW APPLICANTS AND MUST BE FINGERPRINTED. USE ENCLOSED LIVE SCAN FORM.

FULL NAME

HOME ADDRESS

(Street)

(City/State/Zip)

Social Security Number

Birthdate

FULL NAME

HOME ADDRESS

(Street)

(City/State/Zip)

Social Security Number

Birthdate

FULL NAME

HOME ADDRESS

(Street)

(City/State/Zip)

Social Security Number

Birthdate

FULL NAME

HOME ADDRESS

(Street)

(City/State/Zip)

Social Security Number

Birthdate

7.

ARRESTS OR CONVICTIONS ­ NEW APPLICANTS Have any of the new applicants listed in item 6 been arrested or convicted of a crime other than traffic violation(s) within the past 10 years? NO YES If YES, give the name(s) of the applicant(s) involved and completed details on a separate sheet.

8.

APPLICANT HISTORY ­ NEW APPLICANTS A. Have any of the new applicants listed in Item 6 been REFUSED THE ISSUANCE of a vehicle dealer, salvage vehicle agent, or broker license? NO B. YES If YES, give the name(s) of the applicant(s) involved and complete details on a separate sheet.

Have any of the new applicants listed in item 6 had a vehicle dealer, salvage vehicle agent or broker license REVOKED OR SUSPENDED IN MICHIGAN OR ANY OTHER STATE? NO YES If YES, give the name(s) of the applicant(s) involved and complete details on a separate sheet. Within the past 5 years, has any new applicant listed in Item 6 been licensed in Michigan or any other state as a VEHICLE DEALER, SALVAGE VEHICLE AGENT, OR BROKER? YES If YES, complete the following and complete 8D (attach additional sheets if necessary). APPLICANT NAME DEALERSHIP NAME DEALERSHIP ADDRESS DEALER LICENSE NUMBER DATES LICENSED From: To: DEALERSHIP TELEPHONE # (

C.

NO APPLICANT NAME DEALERSHIP NAME

DEALERSHIP ADDRESS DEALER LICENSE NUMBER DATES LICENSED From: To: DEALERSHIP TELEPHONE # (

)

)

8.

APPLICANT HISTORY ­ NEW APPLICANTS -- CONTINUED D. Within the past 5 years, has any new applicant listed in Item 6 been employed as an AGENT FOR ANY DEALER in Michigan or any other state? NO APPLICANT NAME DEALERSHIP NAME JOB TITLE YES If YES, complete the following (attach additional sheets if necessary): APPLICANT NAME DEALERSHIP NAME JOB TITLE

DATES EMPLOYED DATES EMPLOYED From: To: From: To: E. Is any new applicant listed in Item 6 RELATED BY BIRTH OR MARRIAGE to a currently or previously licensed Michigan vehicle dealer, salvage vehicle agent, or broker? NO APPLICANT NAME YES If YES, complete the following (attach additional sheets if necessary): APPLICANT NAME LICENSED DEALER NAME RELATIONSHIP TO LICENSED DEALER DEALERSHIP NAME DEALER LICENSE # DEALERSHIP ADDRESS

LICENSED DEALER NAME RELATIONSHIP TO LICENSED DEALER DEALERSHIP NAME DEALER LICENSE # DEALERSHIP ADDRESS F.

5- YEAR EMPLOYMENT HISTORY ­ NEW APPLICANTS For each new applicant listed in Item 6, please complete the employment history information below. Attach additional sheets if necessary. If self-employed ­ list name, business address and type of business. If unemployed ­ list name and dates of unemployment APPLICANT NAME APPLICANT NAME EMPLOYER NAME EMPLOYER ADDRESS JOB TITLE (if self-employed or unemployed, indicate that here) EMPLOYER NAME EMPLOYER ADDRESS JOB TITLE (if self-employed or unemployed, indicate that here) To:

9.

DATES EMPLOYED DATES EMPLOYED From: To: From: SIGNATURES AND CERTIFICATIONS ­ ALL APPLICANTS IN ITEM 6 MUST SIGN BELOW

I/we certify that the statements contained in this application are true. I/we as owner(s), partner(s), officer(s) or director(s) of the corporation have the authority to sign this application. I/WE UNDERSTAND THAT ANY MISLEADING, INCOMPLETE, OR FALSE STATEMENTS MAY BE GROUNDS FOR DENIAL OF THIS APPLICATION OR SUSPENSION OR REVOCATION OF THE DEALER LICENSE ISSUED. I/we hereby grant the licensing authority in any state or jurisdiction listed in items 8B, 8C, and 8D the authority to release information to the Secretary of State or his/her deputies regarding any previous license applications, licensing history, and disciplinary actions or sanctions. I/we certify that the persons named on this license are not acting as the alter ego, in the place of, or on behalf of, any other person or persons in seeking this license. I/we stipulate and agree that any legal process affecting this business served on the Secretary of State or his/her deputies shall have the same effect as if personally served on me/us. I/we agree that this appointment shall remain in force as any liability of this business remains outstanding within the State of Michigan.
Printed Name Signature Title Date

Printed Name

Signature

Title

Date

Printed Name

Signature

Title

Date

Printed Name

Signature

Title

Date

RETURN TO: MICHIGAN DEPARTMENT OF STATE LICENSING UNIT LANSING, MI 48918 ALLOW AT LEAST 30 DAYS FOR PROCESSING

LIVESCAN FINGERPRINT REQUEST
Date fingerprinted: __________ Type of picture ID presented: ___________

APPLICANT INFORMATION
Must provide a picture ID to be printed

Applicant Name _______________________________________________
Last, first, middle

Date of Birth ____________

Race ______

Sex ______

Applicant address ______________________________________________ ___________________________________Zip ________ Applicant phone number _________________________________________

REQUESTING AGENCY INFORMATION
Agency ID: 1340A
(RQID)

Agency Name: Bureau of Regulatory Services

Reason fingerprinted:
AR­Department of State, Bureau of Regulatory Services

**Disclaimer: Any and all fingerprints processed with incorrect fingerprint codes/reasons, etc are the responsibility of the REQUESTING AGENCY. MSP will charge for second requests due to incorrect fingerprint reason.
L-1 Identity Solutions 1-800-377-2080 www.L1id.com