DLB-10A Revised 10-2018 (Wrecker Salvage Dealer)
10. 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: ___________________________________________________
_____
(must be registered with Nebraska Secretary of State)
List the names, addresses, and titles of principal officers of the corporation or names and addresses of members of the LLC
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
11. Have any of the named owners:
(a) Ever been found guilty of any felony that has not been pardoned?
(b) Ever been found guilty of any misdemeanor concerning fraud or conversion?
Yes ____ No ____
Yes ____ No ____
Yes ____ No ____
Yes ____ No ____
(c) Suffered any judgment in any civil action involving fraud, misrepresentation
or conversion?
(d) Are any felony charges pending against any of the owners at the present time?
OATH
(All partners must sign the oath)
STATE OF NEBRASKA )
County of ________________________ )
________________________________________________________, being first duly sworn, upon oath deposes and says:
(printed name of individual owner, partners, corporate officer, or LLC member)
That he/she is the applicant who makes the above and foregoing application, that he/she has read the same, knows the
contents thereof, and that all statements therein contained are true.
_______________________________________ ______________________________________
Signature of applicant Signature of applicant
SUBSCRIBED in my presence and sworn to before me this _____day of __________________, _______
_____________________________________________________
(Notary Public)
Submit the completed wrecker/salvage dealer license application and supporting documents to our office. It will be
forwarded to one of our investigators who will contact the applicant to schedule an appointment to inspect the dealership.
No fee is collected until after the wrecker/salvage dealership has been inspected and approved by our office.
After the inspection and upon approval, send to our office the Inspection Report, any additional required items, and the
fee in the proper amount made payable to the Motor Vehicle Industry Licensing Board.
If YES, please give details. Attach a separate sheet of
paper if needed.
_______________________________________________________________________________________________