Motor Vehicle Commission Trenton, New Jersey STATE OF NEW JERSEY P.O. Box 171 Legislation has been approved for the registration of facilities who wish to install sun screening material to motor vehicle windows for medical purposes. We are sending you this copy of the regulations for your information. If after review of the documentation you are interested in being registered, please return the enclosed application along with the required $100.00 application fee. If you have any questions, please call (609)292-4517. Sincerely, Business Licensing Services Bureau Enclosures American LegalNet, Inc. www.FormsWorkFlow.com New Jersey Motor Vehicle Commission Business License Compliance P.O. Box 171 Trenton, New Jersey 08666-0171 609-292-4517 APPLICATION FOR SUN SCREEN MATERIAL INSTALLATION FACILITY LICENSE FOR OFFICE USE ONLY License No.______________________________ Date:______________________________ Reg. No._________________________________ Approved by:______________________________________________ ________________________________________________________________________________________________ Corp Code:______________________________________________ 1. __________________________________________________ ______________________________ Name of Business (if corporation, corporate name) _____________________________________________________ Business Phone 2. Please Check Street Address Corporation Partnership Proprietorship _____________________________________________________ City State Zip All applicants please provide the following information and attach copies of the proof thereof: Other__________________________ A. New Jersey Sales Tax No._______________________________ B. New Jersey Unemployment Registration No._________________________________ C. Federal Employer Identification No.________________________________________ Complete the following for proprietor, partners, or coporate officers: Name Title Home Address Telephone No. 4. Have the owners, partners or corporate officers ever been charged or convicted of violating the Consumer Fraud Act N.J.S.A. 56:8-1 et seq., or any regulations adopted thereunder? Yes No If yes, explain: 5. Have the owners, partners or corporate officers ever been denied, or had suspended or revoked, a license or registration to engage in the business, profession, or occupation licensed or registered under the laws of any state? Yes No If yes, explain: American LegalNet, Inc. www.FormsWorkFlow.com 6. Have the owners, partners, or corporate officers any interest in other sun-screening material installation facility or any motor vehicle related business? Yes No If yes, give name and license number of business. 7. Does any stockholder own more than 10% of the corporations stock? Yes If yes, give name, address and holding No 8. ____________________________________________ Place of Incorporation ____________________________________________ Date of Incorporation ____________________________________________ Date of authorization to do business in New Jersey ATTAC H C O P Y O F T H E C E R T I F I C A T E O F INCORPORATION WHICH HAS BEEN FILED WITH THE N.J. SECRETARY OF S T A T E . F o r e i g n Corporations must subm i t a c o p y o f t h e i r Authorization to do business in New Jersey as a Foreign Corporation in addition to a copy of the i r corporate papers. 9. 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 Director shall be reasonable and proper grounds for registration suspension or revocation. He further agrees to notify Motor Vehicle Services 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. 10. 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 am_______________________________________ of the above business and the information I have submitted is true to the best of my knowledge. ____________________________________________ Signature and Title of Applicant I, the undersigned, hereby certify that I am Secretary of the above Corporation and have witnessed the signature of the __________________________________________________ who is __________________________________ of said President, Vice President Corporation. _____________________________________________ Signature of Secretary BLC-69A (R7/03) American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS LICENSE COMPLIANCE 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 (7/03) 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? Yes No 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