Free 40248.FH11 - Indiana

APPLICATION FOR SALVAGE MOTOR VEHICLE BUSINESS LICENSE
State Form 40248 (R6 / 5-08)

* This agency is requesting the 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.

INSTRUCTIONS:

1. Complete application in full. 2. Do not send payment with application. 3. Mail to Secretary of State, Dealer Division, 6400 East 30th Street, Indianapolis, Indiana 46219.

Reset Form

1. Name of business Business address (number and street, city, state, and ZIP code) County Telephone number ( )

County code

2. Retail merchants certificate number

3. Federal ID number

If you have a rural location, please give directions to place of business

4. Check the function(s) for which you wish to be licensed: Salvage recycler Salvage rebuilder Hulk crusher Used parts dealer

5. Check the activities to be conducted at this location: 1. Selling used major component parts of vehicles; 2. Wrecking or dismantling vehicles for resale of their major component parts; 3. Rebuilding wrecked or dismantled vehicles; 4. Possessing two (2) or more inoperable vehicles subject to registration for more than thirty (30) days; 5. Engaging in the business of storing, disposing, salvaging, or recycling of vehicles, vehicle hulks, or the parts of vehicles. 6. List any branch or supplemental locations required to be licensed to perform any of the above activities: NAME ADDRESS (number & street, city, state, & ZIP code) ( ( ( ( TELEPHONE NUMBER ) ) ) ) COUNTY

7. Has any owner, partner, officer, director, or agent of applicant had a civil judgment or criminal conviction against them for any violation of any State or Federal laws concerning the sale, distribution, financing, or insuring of motor vehicles or parts within the last three years? Yes No If Yes, please give details:

8. Has any owner, partner, officer, director or agent of applicant had a Salvage Operator license suspended or revoked or had an application for a Salvage Operator license rejected in this or any other state within the last three years? Yes No If Yes, explain:

TO BE COMPLETED BY LOCAL ZONING BOARD
I, the undersigned, verify compliance with local zoning ordinances or other local ordinances for conducting Salvage Operator business at the address cited above.
Signature Printed or typed name Authorized agency Title Date (month, day, year)

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9. Check type of business organization: Sole Proprietorship Partnership Corporation Unincorporated association

10. If Sole Proprietorship, list information for owner. If Partnership, list information for all partners. If Corporation, list information for all officers. If Unincorporated Association, list information for all managers or chief administrative officials. NAME SOCIAL SECURITY NUMBER * TITLE ADDRESS (number & street, city, state, & ZIP code) TELEPHONE NUMBER ( )

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( 11. State the name and address of the person upon whom legal service of process may be made:
Name Address (number and street, city, state, and ZIP code)

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12. If corporation, give the date and state of incorporation.

13. If foreign corporation, state the date of admission to do business in Indiana.

14. Has any owner, partner, officer, or director of applicant owned or worked for another salvage operator in this or any other state within the last three (3) years? Yes No If Yes, give name of individual and name and address of business.
Name of individual Address of business (number and street, city, state, and ZIP code) Name of individual Address of business (number and street, city, state, and ZIP code) Name of business Name of business

15. Indicate whether your establishment is owned or leased. 14. Is this location devoted solely to the business of recycling, rebuilding, dismantling, crushing and/or exchanging used motor vehicle parts / vehicles?
Yes No

If no, explain:

PLEASE NOTE:

Every disposal facility or automotive salvage rebuilder shall keep and maintain records on the current model year and immediate four (4) preceding model years for all salvage motor vehicles as indicated in 140 IAC 3-3-8 (Vehicle Register and Major Component Parts Register) and required by IC 9-22-3-20. Any salvage motor vehicle or major component part which is subject to recordkeeping procedures by law and per regulation which has been acquired and entered into the vehicle register or major component parts register shall be subject to recordkeeping for disposal purposes even though the sale of such vehicle or part is beyond the five (5) year provisions of 140 IAC 3-3-8. All records required to be maintained under IC 9-22-3-21 and inventory are subject to inspection by a police officer or bureau representative during normal business hours.

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 Printed or typed name Title Date (month, day, year)