Free MV2844 - Wisconsin

ENTITY/OWNER STATEMENT
MV2844 3/2005

Clear Form

Wisconsin Department of Transportation Dealer Section PO Box 7909 Madison, WI 53707-7909 608-266-1425

NOTE: Complete one form for EACH owner, partner, corporate officer, shareholder of 10% or more of a corporation, association member, Limited Liability Company - LLC member or LLC manager.
Legal Business Name Business / Your Position - Check all that apply.

Sole Proprietor

Partnership

Corporation Officer Shareholder

Limited Liability Company Manager Member

Association

What percentage of the business, stock in the corporation, or interest in the LLC do you own? Your Full Legal Name Residence Address: Street or RFD, City, State, ZIP Code Area Code - Telephone Number, Residence Driver License Number Birth Date Social Security Number - For identification purposes

Provide complete answers to the following questions.
List any other business in which you are engaged. List any ownership interests in other dealerships. Have you ever been licensed as a dealer in Wisconsin?

No No No No

Yes - Year Last Licensed: Yes - Give State and Year Last Licensed: Yes - Give State and Year: Yes - List date, state, charge and court; continue on back if needed.

Have you ever been, or are you currently licensed as a dealer in another state? Has your dealer license ever been denied, suspended or revoked? Have you every been convicted of a crime?

Are any criminal charges pending against you?

No

Yes - List date, state, charge and court; continue on back if needed.

List any former names by which you were known.

False statements on this application are punishable by law and may result in denial, suspension or revocation of your dealer license. The undersigned states that she or he is owner, partner, officer, association member, LLC member or LLC manager of the facility named on this application and that the answers contained in this application are true.

(Applicant Signature)

(Date)