DLB-10A
STATE OF NEBRASKA
NEBRASKA MOTOR VEHICLE INDUSTRY LICENSING BOARD
301 CENTENNIAL MALL SOUTH, P.O. BOX 94697, LINCOLN, NE 68509
402-471-2148
FEE: $70
(Collected after inspection and approval)
Application for: MOTOR VEHICLE WRECKER OR SALVAGE DEALER LICENSE
Application of _________________________________________________________________________________________________
(Name of wrecker/salvage dealership under which business is conducted)
for a license to engage in the business of selling or exchanging motor vehicle or trailer parts and accessories in accordance with the Motor Vehicle Industry
Regulation Act, the rules and regulations adopted and promulgated by the board, and any amendments existing on the date of application, and in
connection herewith makes the following Material Statements:
1. Address of wrecker/salvage dealership:
___________________________________________________________________________________________________________
(Street) PO Box (City) (State) (Zip Code)
County: _________________________ If the above address is a rural location, please give directions to find the dealership:
_________________________________________________________________________________________
2. (a) Dealership Telephone Number: (______)______________ FAX: (______)______________
(b) Your declared office hours: _______ a.m. to _______ p.m. (must be open 40 hours per week, 20 of those during regular business hours)
3. Does the dealership location conform to applicable zoning laws? ______
(Please supply a zoning permit or letter from the proper authority confirming your zoning compliance.)
4. Describe fully the building and actual premises where the business is or will be operated (including square feet of building and lot).
___________________________________________________________________________________________________________
5. Indicate whether the proposed location is owned or leased by the applicant _________________. If the location is leased, a copy of the
lease that does not end before December 31st of the current year must accompany this application.
6. Will the building and actual premises be maintained as a bona fide and established place of business? ________
7. Will all motor vehicle wrecker or salvage dealer records be kept separately from other business or personal records? _______
8. Submit with this application a photograph of the place of business, showing the permanently erected dealership sign in the photo.
(The dealership name on the sign must be in letters at least eight inches in height.)
9. Ownership of the dealership (check only one):
___ Individual Owner: name, address and social security number of the Individual Owner
___________________________________________________________________ Social Security Number ___________________
___ Partnership: list the names and addresses of all partners
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___Corporation or Limited Liability Company: _______________________________________________(registered with Nebraska Secretary of State)
List the names, addresses, and titles of principal officers of the corporation or names and addresses of the members of the LLC
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
10. (a) Have any of the above persons ever been found guilty of any felony that has not been pardoned? Yes ____ No ____
(b) Have any of the above persons ever been found guilty of any misdemeanor concerning fraud or conversion? Yes ____ No ____
(c) Have any of the above persons suffered any judgment in any civil action involving fraud, misrepresentation or conversion? Yes ____ No ____
(d) Are any felony charges pending against any of the above persons at the present time? Yes ____ No ____
If YES, please give details. ____________________________________________________________________________________
Attach a separate sheet of paper if needed.
THE OATH ON THE REVERSE SIDE MUST BE SIGNED AND NOTARIZED
