Free 47584.FH11 - Indiana


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APPLICATION FOR WATERCRAFT DEALER LICENSE
State Form 47584 (R / 5-08)

SECRETARY OF STATE - DEALER DIVISION 6400 East 30th Street Indianapolis, Indiana 46219 Telephone: (317) 591-5304

* This agency is requesting disclosure of personal information, including Social Security Number and Federal Identification Number, according to IC 4-1-8-1; disclosure is mandatory and this application cannot be processed without it.

INSTRUCTIONS:

1. Complete application in full; failure to provide any information may prevent this application from being processed. 2. If applying for a Class A license, give the address of each location to be licensed. Attach an additional sheet for each additional location; giving name, address and telephone number. 3. Please provide a copy of your Indiana Registered Retail Merchant Certificate.
If duplicate application, license number

Type of Application

New

Duplicate
Owner's Social Security number *

Name of owner / sole proprietor (last name, first name, middle initial)

Legal name of business

Telephone number

(
Business location address (number and street, city, state, and ZIP code)

)

If above is a rural location, please give directions to place of business

Liability insurance must meet the following requirements: The policy must have limits of not less than one hundred thousand dollars ($100,000) for bodily injury to one person, three hundred thousand dollars ($300,000) per accident, and fifty thousand dollars ($50,000) for property damage. These minimum amounts must be maintained during the time the license is valid.
Name of insurance carrier Policy number Date of expiration (month, day, year)

Retail Merchants Certificate number

Federal identification number

Indicate the type of watercraft sold

N
Indicate your type of business

New Only Dealer Discount

U C D

Used Only Manufacturer Distributor

B E D

New and Used Broker Wholesale Dealer G H Transfer Auctioneer

A B

Do you intend to purchase a dealer registration?

How many watercraft do you expect to sell during the next twelve (12) months?

Yes
Is this business seasonal?

No
If Yes, check months or partial months in business JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Yes

No

Indicate the business' principal type of product sold or service rendered

Indicate whether your established place of business is: (check one)

Owned
Indicate whether applicant is: (check one)

Leased

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. If additional space is necessary, enclose a sheet listing the remaining names, titles, home addresses and home telephone numbers.
NAME SOCIAL SECURITY NUMBER TITLE HOME ADDRESS (number and street, city, state, & ZIP code) HOME TELEPHONE NUMBER

Has any business you've been involved with currently or in the past had a dealer license suspended or revoked or had an application for dealer license rejected in this state within the last three (3) years?

Yes
If Yes, please give details

No

PLEASE NOTE: Every Manufacturer, Distributor, Retail or Wholesale Dealer must file with the Secretary of State, Dealer Department, a current copy of each franchise to which it is a party, or, if multiple franchises are identical except for stated items, a copy of the form franchise with supplemental schedules of variations from the form. All books, records and files relating to applicant's inventory and watercraft titles must be kept at the established place of business and be available for inspection. I hereby certify, under 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 owner, partner, or officer Date (month, day, year)

Printed or typed name

Title

Before submitting this application, have you: Enclosed a copy of each franchise agreement; Enclosed a copy of your Indiana registered Retail Merchant Certificate; Enclosed your SR 23 (insurance policy); Enclosed a sheet giving the name, Social Security number, address, and telephone number of each additional business location; Enclosed a sheet listing the remaining owners names, Social Security numbers, titles, home addresses, and home telephone numbers.