NEW JERSEY MOTOR VEHICLE COMMISSION Trenton, New Jersey 08666 STATE OF NEW JERSEY P.O. Box 171 Dealer Section Enclosed is an application and supplemental forms necessary to apply for a Motor Vehicle Junkyard license. In order to qualify for licensure, the facility must be adjacent to a major street/highway, you have been issued a Used Motor Vehicle Dealer license and an exterior sign must be displayed which reflects the business name. In addition, we also require a certificate of insurance that reflects liability insurance coverage in the minimum amounts of $15,000/$30,000 bodily injury and $5,000 property damage and a $150.00 licensing fee. If you have any questions, please call (609) 292-6500 ext.5014. Sincerely Business License Services BLC-2 (R 01/08) New Jersey is an Equal Opportunity Employer American LegalNet, Inc. www.FormsWorkFlow.com Business License Services PO Box 171 Trenton, New Jersey 08666-0171 Motor Vehicle Commission APPLICATION FOR LICENSE FOR OFFICE USE ONLY License No. Date Reg. No. Email Approved by The undersigned hereby applies for the license(s) checked in Part 3 and submits the following certified statement: Corp Code 1. Business phone Name of Business (if corporation, corporate name) ____________________________________________________________________ Trade Name 2. Please Check [ ] Corporation Street Address [ ] Other Zip Code City County All applicants please provide the following information and attach copies of proof thereof: A. NJ Sales Tax Identification Number B. NJ Unemployment Registration Number C. Federal Employer Identification Number 4. Complete the following for proprietor, partners, or corporate officers: Name 5. Title 3. Please Check appropriate Box for License: [ ] Leasing Company [ ] Driving School [ ] Moped Dealer [ $ ] Junkyard [ ] Private Inspection Facility [ ] Fleet Fleet Inspection Facility [ ] Other Home Address [ [ [ [ [ ] New & Used Motor Vehicle Dealer ] Auto Body Repair Facility ] Used Motor Vehicle Dealer ] Fleet DEIC ] DElC Telephone Number Have the owners, partners, or officers ever been arrested, charged or convicted of a criminal or disorderly persons offense in this or any other state? [ ]Yes [ ]N o 6 [ ]Proprietorship [ ] Partnership if yes, explain: Do you knowingly intend to employ a person who has been convlcted of the above, or any other crime or who was previously licensed as any in this or any other state and was subject to license suspension or revocation? Of the above [ ]Yes [ ]No 7 Give name and address of person Have the owners, partners or corporate officers ever held any of the above licenses? [ ] Yes [ ]N o If yes, please explain the type of license and license numbers American LegalNet, Inc. www.FormsWorkFlow.com 8. Was the license ever suspended or revoked? [ ]Yes [ ]N o 9. If yes, explain: Have the owners, partners or corporate officers, agents or employees of your organization ever used an alias or been known by any other name [ ]Yes If yes, explain: [ ]N o 10. Does any stockholder own more than 10% of the corporation's stock? If yes, give name, address and holding [ ] Yes [ ]N o 11 Attach copy of the Certificate of Incorporation/Formation which has been filed with the N.J. Secretary of State. Foreign Corporations must submit a copy of their Authorization to do business in New Jersey as a Foreign Corporation in addition to a copy of their corporate/formation papers. Place of Incorporation/Formation Date of Incorporation/Formation Date of authorization to do business in New Jersey 12 The applicant certifies all information contained herein is true and agrees any untruthful representation and any violation of the applicable statutes and regulations promulgated by the Commission shall be reasonable and proper grounds for license suspension or revocation. He further agrees to notify the Commission immediately of any change in the status of the business or of any other information which would change the answers and statements in this application or supplement thereto. 13 The individual(s) signing this application certify that they have read the applicable statutes and are thoroughly familiar with the details and penalties provided. I, the undersigned, hereby certify that I _________________of the above business previously named____________________________________________ Owner, Partner, Officer, Member and that the information I have submitted is true to the best of my knowledge. _______________________________________________________________ Print Name of Applicant Signature and Title of Applicant the undersigned, hereby certify that I am Secretary/Member/Partner of the above Corporation and have witnessed the signature of__________________________ who is of said corporation. President, Vice-President or Member Signature of Secretary/Member/Partner APPROVAL CERTIFICATE Clerk of the Municipality of County of (Print Name) State of New Jersey, hereby certify that the Municipal Governing Body or Zoning Commission has approved the location. establishment and maintenance of the business checked below: [ ] Leasing Company [ ] Fleet DElC [ ] Driving School [ ] New & Used Motor Vehicle Dealer [ ] Moped Dealer [ ] Auto Body Repair Facility [ ] Other [ ] Junkyard [ ] Private Inspection Facility [ ] Used Motor Vehicle Dealer [ ] Fleet Inspection Facility [ ] DElC located at Complete Address _____________________________________________________ Print Name of Municipal or Zoning Board Clerk BLC-183 (R12/04) Signature of Municipal or Zoning Board Clerk Date American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS LICENSE SERVICES SUPPLEMENTARY APPLICATION BUSINESS NAME BUSINESS PHONE # 1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX, IF ANY 2. STREET ADDRESS CITY STATE HOME PHONE # 3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS? 4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU W E R E IN EACH STATE OR COUNTRY. 5. DATE OF BIRTH (MO. DAY, YEAR) 7. SEX 6. PLACE OF BIRTH: (CITY, STATE OR FOREIGN COUNTRY) 8. HEIGHT 11. SOCIAL SECURITY NUMBER 10. COLOR OF EYES 9. WEIGHT 12. DRIVER LICENSE NUMBER (STATE) 13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE, VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS? YES NO IF YES, ATTACH EXPLANATION DESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE. 14. I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE: DATE 1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX. IF ANY 2. STREET ADDRESS CITY STATE 3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS? HOME PHONE # 4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU WERE IN EACH STATE OR COUNTRY. 5 DATE OF BIRTH (MO. DAY, YEAR) 7. SEX 11. SOCIAL SECURITY NUMBER 6. PLACE OF BIRTH: (CITY. STATE OR FOREIGN COUNTRY) 8. HEIGHT 9. WEIGHT 10. COLOR OF EYES 12. DRIVER LICENSE NUMBER (STATE) 13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE, VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS? YES NO IF YES, ATTACH EXPLANATION DESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE. 14. I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE: BLC-205B (R12/03) DATE American LegalNet, Inc. www.FormsWorkFlow.com Business Licensing Services Bureau P.O. Box 171 Trenton, New Jersey 08666-0171 (609) 292-6500 #5014 _______________________________________________________________________________________ CHILD SUPPORT CERTIFICATION FORM _________________________________________ Business Name _________________________________________ Applicant’s Name (Print) __________________ Date of Birth _________________________________________ Social Security Number Under the provisions of N.J.S.A. 2A:17-56.7 et seq., responses to the questions listed below are required. Misstatements will be just cause to take administrative action including, but not limited to, denial of licensure, immediate suspension or revocation of the license. 1. Do you have a child support obligation? Yes No 2. If yes, do the arrearage amounts equal or exceed the amount of child support payable for six months? No Yes 3. Are you subject to a child-support warrant? Yes No I certify that the foregoing responses made by me are true and I am aware that the making of false statements may subject me to contempt of court. ______________________________________________ __________________ Signature Date BLS-43 (R 9/09) On the Road to Excellence www.njmvc.gov New Jersey is an Equal Opportunity Employer American LegalNet, Inc. www.FormsWorkFlow.com