Free 43595.FH11 - Indiana

MOTOR VEHICLE BUSINESS OFFSITE LICENSE APPLICATION
State Form 43595 (R3 / 5-08) Approved by State Board of Accounts, 2008

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SECRETARY OF STATE - DEALER DIVISION 6400 East 30th Street Indianapolis, Indiana 46219

INSTRUCTIONS:

1. Complete application in full; failure to provide any information may prevent this form from being processed. 2. Upon completion, this form will be treated as a PUBLIC RECORD.

* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it. Business name in which license will be issued Business address (number and street, city, state, and ZIP code) Temporary location (number and street, city, state, and ZIP code) Dealer number Duration of event (not to exceed 10 days) Retail merchants certificate number Type of event Telephone number

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From:

To:

Indicate the type of premises at which the event will be held:

Building Tent Open Parking Area Sunday Classic / Antique Auto Auction Other (explain): _________________________________________________________________
Indicate whether applicant is:

Sole Proprietorship

Partnership

Corporation

List the names, Social Security Numbers, titles, home addresses, and home telephone numbers of all owners, if sole proprietorship; all partners, if partnership; and all officers and directors, if corporation.
NAME SOCIAL SECURITY NUMBER* TITLE HOME ADDRESS (number and street, city, state, & ZIP code) HOME TELEPHONE NUMBER

To be completed by the Executive of City, Town or County, as set forth in IC 36-1-2-5 I, the undersigned, verify compliance with local zoning ordinances or other local ordinances for conducting Motor Vehicle Business at the temporary location cited above.
Authorized signatory Name of authorizing agency Title Date (month, day, year)

CERTIFICATION Please read each statement carefully, check each box, and initial after each statement. This temporary location for the proposed offsite sale is within twenty (20) miles of the applicants established place of business (see IC 9-23-2-7(c)). ______
Initial

The applicant has not applied for more than three (3) offsite sales in the currect year (see IC 9-23-2-7(g)). ______
Initial

I hereby certify, under penalty of perjury, that I am authorized to make this application and that the answers and information in this application are true and correct.
Signature of owner, partner, or officer Print or type name of owner, partner, or officer Title Date (month, day, year)