Free MDOS Form - Michigan

Clear Form
AR-0175 (10/2003) By Authority of Public Act 300 of 1974

MOTOR VEHICLE REPAIR FACILITY REGISTRATION CHANGE OF OFFICER, DIRECTOR, STOCKHOLDER APPLICATION

MICHIGAN DEPARTMENT OF STATE DEPARTMENT USE ONLY: Licensing Unit Lansing, Michigan 48918 Approved: (517) 636-6400; fax (517) 335-2810 By: www.Michigan.gov/sos

IF THE BUSINESS ENTITY HAS CHANGED, YOU MAY NOT USE THIS FORM. YOU MUST APPLY FOR AN ORIGINAL REGISTRATION.
1. BUSINESS NAME and REPAIR FACILITY REGISTRATION NUMBER
Business Name (Type or print exactly as it appears on your wall license.)

Repair Facility Registration Number

2. BUSINESS LOCATION AND BUSINESS TELEPHONE NUMBER

(
Street City County Zip Code

)

Telephone Number

3. CORPORATE OFFICERS, DIRECTORS, AND STOCKHOLDERS OWNING 10% OR MORE OF THE STOCK
Type or print the information for ALL persons to be listed on the registration (both new and continuing). Attach additional sheet(s), if necessary. A. Full Legal Name Home Telephone B. Full Legal Name Home Telephone C. Full Legal Name Home Telephone D. Full Legal Name Home Telephone Home Address: Street Date of Birth Social Security Number City/State Driver License Number Zip Code Home Address: Street Date of Birth Social Security Number City/State Driver License Number Zip Code Home Address: Street Date of Birth Social Security Number City/State Driver License Number Zip Code Home Address: Street Date of Birth Social Security Number City/State Driver License Number Zip Code

Complete Items 4 and 5 only as they relate to NEW corporate officers, directors, or stockholders. 4. PREVIOUS REPAIR FACILITY REGISTRATION(S)
Have any of the NEW applicants listed in Item 3 ever owned or participated in any repair facility? If your answer is YES, type or print complete details below. Attach additional sheet(s), if necessary. NO YES

Applicant's Name Applicant's Name Applicant's Name Applicant's Name

Business Name Business Name Business Name Business Name

Registration Number Registration Number Registration Number Registration Number

Last Year Registered Last Year Registered Last Year Registered Last Year Registered

(over)

5. ARRESTS OR CONVICTIONS
Have any of the NEW applicants listed in Item 3 been arrested or convicted of a crime other than a traffic violation in Michigan or any other state within the past ten (10) years? NO YES If your answer is YES, type or print the name(s) of the applicant(s) involved and complete details of all arrests or convictions that took place in the past ten (10) years. Attach additional sheet(s), if necessary. Name(s) of Person(s) Arrested or Convicted, and Details

Enter Details Here:

Date(s) of Arrest(s) or Conviction(s)

Enter Dates Here:

Court(s) of Record

Enter Court(s) of Record here:

City and State

Enter City and State Here:

6. READ CAREFULLY BEFORE SIGNING. ALL PERSONS LISTED IN ITEM 3 MUST SIGN.
I certify that the statements contained in this application are true and I, as an officer, director, or stockholder of the corporation, have authority to sign this application and to make the statements contained herein. I understand that any misleading, incomplete, or false statement shall be grounds for denial of this application or the suspension or revocation of my registration. I 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 and all other owners of this business, if any. I further agree that this appointment shall remain in force as long as any liability of this business remains outstanding within the State of Michigan.

Signature

Title

Date

Signature

Title

Date

Signature

Title

Date

Signature

Title

Date

Signature

Title

Date

Signature

Title

Date