NEW JERSEY MOTOR VEHICLE COMMISSION For Used Motor Vehicle Dealer OR for New And Used Motor Vehicle Dealer Trenton, New Jersey 08666 STATE OF NEW JERSEY P.O. Box 171 Dealer Section PLEASE READ CAREFULLY Enclosed are applications and supplemental forms necessary to apply for a new and used motor vehicle dealer license. If you sell motor vehicles, you must be licensed. Each applicant for a motor vehicle or moped license shall have established and maintained a place of business at the time such license is issued. An established place of business must have an exterior sign, facilities to display vehicles offered for sale, and be in conformance with all municipal requirements. No license approval will be granted when the applicant intends to use the premises of a currently licensed dealer or the premises of the proprietor of an allied business. A licensed motor vehicle dealer can also deal in mopeds and leased vehicles with no additional license required. A licensed dealer is restricted to moped sales only. When all investigations are concluded and the applicant is approved, a certified check or money order will be requested, as well as a current certificate reflecting liability coverage in the minimum amounts of $100,000 per person/incident up to $250,000 per incident for bodily injury or death, $25,000 per incident for property damage and $250,000 combined personal injury and property damage per incident for all owned or fleet vehicles. Such insurance certificate must contain a 30-day cancellation clause. In addition to the above, the "dealer" must provide a surety bond in favor of the State of New Jersey in the amount of $10,000. The bond must be executed by a surety company authorized to transact business in the State. The bond must be for a 12-month term and must be renewed at expiration for successive 12-month periods. The fee for the license is $100 plus an additional fee of $257.50 for one set of registrations and five license plates, or $77.00 for one set of motorcycle registrations and three license plates. If you have any questions, please call (609) 292-6500 ext. 5014. Thank you for your cooperation in this endeavor. Sincerely, Business Licensing Services Bureau BLC-2 (R 01/08) New Jersey is an Equal Opportunity Employer American LegalNet, Inc. www.FormsWorkFlow.com Motor Vehicle Commission (609) 292-6500 ext.5014 NEW JERSEY DEALER INITIAL APPLICATION CHECKLIST In order to insure prompt processing of your Dealer License Application, please submit all items checked! License fee ($100.00). Certified check or money order payable to the NJ-MVC. Registration fee (auto $257.50) (motorcycle $77.00). Certified check or money order payable to the NJ-MVC. License application with municipal approval. Supplemental application for each owner, partner(s), officer(s) or member(s). Child support certification for each owner, partner(s), officer(s) or member(s). Receipt(s) which indicates the owner, partner(s), officer(s) or member(s) have been fingerprinted. Copy of the driver license of the owner, partner(s), officer(s) or member(s). Passport size color photograph of the owner, partner(s), officer(s) or member(s) – (please identify the individual on the reverse side of the picture). Copy of Incorporation/Formation Papers showing the filing date with the NJ Division of Revenue. Copy of Alternate/Fictitious Name Filing Certificate (if applicable). Copy of property deed or lease. Business hour(s) (if open less than 48 hours). Copy of Federal EIN Registration Certificate. Copy of NJ Certificate of Authority for Sales Tax. Original $10,000.00 Surety Bond (copy not acceptable). Due after preliminary license approval. Original Certificate of Liability Insurance in the amount of $100,000 per person/incident up to $250,000 per incident for bodily injury or death, $25,000 per incident for property damage and $250,000 combined personal injury and property damage per incident covering all dealer plates and the NJMVC-Dealer Unit, PO Box 171, Trenton 08666 listed as the certificate holder. Due after preliminary license approval. Listing of authorized signatories (those authorized to sign Motor Vehicle documents on behalf of the dealership. Photographs/plans clearly depicting the complete premises and signage which the dealer intends to conduct business. Certification which verifies that those listed as authorized signatories have not been convicted of fraud or misrepresentation. Please submit a copy of the phone bill or installation order for the business. *Do not provide proof of liability insurance and surety bond until you receive preliminary notice of license approval. American LegalNet, Inc. www.FormsWorkFlow.com New Jersey Motor Vehicle Commission Trenton, New Jersey 08666 STATE OF NEW JERSEY Business Licensing Services Bureau P.O. Box 171 Trenton, New Jersey 08666-0171 NOTICE MOTOR VEHICLE INSTALLMENT SELLERS LICENSE All licensed motor vehicle dealers who sell motor vehicles to retail buyers and who wish to execute retail installment contracts in connection with such sales shall be required to obtain a motor vehicle installment seller's license from the Commissioner of the Department of Banking. Failure to obtain the required motor vehicle installment seller's license from the Commissioner of Banking before engaging in such business shall subject you to penalties provided by the Retail Installment Sales Act of 1960, N.J.S.A. 17:16C et.seq. Additional information regarding this New Jersey statute and the application form to be used in applying for a motor vehicle installment seller's license must be obtained from: License Section N.J. Department of Banking P.O. Box 040 Trenton, NJ 08625-0040 609-292-5340 NOTE: Applications for this license should be obtained as soon as possible. Timely filing and license issuance will ensure your ability to discount contracts to your financial institution or licensed sales finance lender. MV-4 (R 9/07) American LegalNet, Inc. www.FormsWorkFlow.com Business Licensing Services Bureau 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 Was the license ever suspended or revoked? 8. [ ]Yes [ ]N o 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 9. [ ]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 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. 11 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 Signatureof Secretary/Member/Partner APPROVAL CERTIFICATE (Print Name) Clerk of the Municipality of 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 County of [ ] Used Motor Vehicle Dealer [ ] Fleet Inspection Facility [ ] DElC located at Complete Address _____________________________________________________ Print Name of Municipal or Zoning Board Clerk BLC-183 (R 9/07) Signature of Municipal or Zoning Board Clerk Date American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS LICENSING SERVICES BUREAU 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 EXPLANATIONDESCRIBING 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 (R 9/07) 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 Motor Vehicle Commission Trenton, New Jersey STATE OF NEW JERSEY BUSINESS LICENSING SERVICES BUREAU TO ALL MOTOR VEHICLE DEALERS The Motor Vehicle Commission has now established a live fingerprint scan process to streamline criminal background checks required as a condition of certification as a licensed Motor Vehicle Dealership. As part of the Business License application process, it is required that all proprietors, partners and corporate officers schedule an appointment with the State’s fingerprint scan vendor MorphoTrak (formerly Sagem Morpho, Inc.). All you need to do is call this toll free number 1-877-503-5981 (English or Spanish Operators) or TTY-1-800-673-0353 (Hearing Impaired Modem Required) to arrange an appointment to be scanned at an established site. When scheduling your appointment, you will be asked to provide certain personal information including your driver’s license and social security number. Please make sure you have this information available when scheduling your appointment. In addition, you will be asked to provide the following Motor Vehicles identification numbers: ORIGINATING AGENCY REFERRAL NUMBER (ORI) NJ 920530Z AGENCY CASE NUMBER (YOUR DRIVER LICENSE NUMBER) CATEGORY MVK DOCUMENT TYPE RB1 STATUTE N.J.S.A. 39:10-19 NJ MVC DEALER LICENSE Please complete the applicant information form contained on the back of this letter. Though certain information is already filled in, you will need to supply certain personal information in blocks 9 thru 26 as well as your driver’s license number in block 7 which will be used as your agency case number. Please have this form filled in and present it when you appear for your appointment along with the proper photo identification as noted on the back of this letter. After supplying this information you will be scheduled for an appointment at one of the electronic scan sites. You will be required to pay a one-time fee in the amount of $70.25 incorporating all required background checks. Payment must be made at the time of scheduling your appointment. AT THE TIME OF SCANNING YOU WILL RECEIVE A RECEIPT FROM THE STATE’S VENDOR. PLEASE SUBMIT THIS RECEIPT OR A COPY THEREOF AS PART OF YOUR BUSINESS LICENSE APPLICATION PACKAGE. If you have any questions concerning this procedure. Please contact the following area: NEW JERSEY MOTOR VEHICLE COMMISSION BUSINESS LICENSING SERVICES BUREAU DEALER UNIT 609-292-6500 ext.5014 PLEASE BRING THIS LETTER AND PHOTO IDENTIFICATION WITH YOU WHEN YOU APPEAR TO BE FINGERPRINTED. REV 9/09 American LegalNet, Inc. www.FormsWorkFlow.com . www.bioapplicant.com/nj Formerly Sagem Morpho Inc (1) Originating Agency Number (ORI #) (2) Category NJ920530Z (3) Statute Number 39:10-19 MVK (4) Reason for Fingerprinting (5) Document Type NJ DMV DEALERS LICENSE (8) Miscellaneous NEW & USED CAR DEALERSHIP DL# (9) First Name (10) MI (12)Daytime Phone Number ( ) $70.25 RB1 (7) Contributor’s Case # (Unique Identifier) (6) Payment Information (13) Social Security Number (11) Last Name (14) Date of Birth (15) Height (16) Weight - (17) Maiden Name (if married female) (18) Place of Birth (U.S. State –for US Citizen; Country for all others) (19) Country of Citizenship (20) Home Address Address (21) Gender (Select one) (22) Hair Color (Indicate most predominant color, one only) Male ( ) Female ( ) Both ( ) (25) Occupation City (23) Eye Color State Zip (24) Race (Select One) A Asian/ Pacific Islander ( includes Asian Indian) B Black W White ( Includes Hispanic/ Spanish Origin) U Unknown I American Indian / Alaska Native (26) Employer (Name) Employer Address City State Zip APPLICANT INFORMATION – READ THIS FORM CAREFULLY AND FOLLOW ALL INSTRUCTIONS TO COMPLETE THE FINGERPRINT PROCESS. You MUST present this completed form at your appointment to be FINGERPRINTED. NO EXCEPTIONS ALLOWED. Applicants without forms or with incomplete forms will not be printed. IDENTIFICATION IS REQUIRED- ACCEPTABLE ID REQUIREMENTS –ID MUST include Photo, Name, Address (Home/ Employer) and Date of Birth. Acceptable ID MUST be issued by a Federal, State, County or Municipal entity for Identification purposes. Examples of acceptable ID are: 1) Valid Photo Drivers License or Valid Photo ID issued by any State DMV or NJ MVC, 2) Passport. Acceptable ID MUST meet all of the underlined requirements above and MUST be present on one (1) ID. Combinations of documents are NOT acceptable. If acceptable ID is not presented you will not be fingerprinted. For applicants who are required to pay for their own fingerprinting fees, payment is required at the time of scheduling. Payment may be made with a credit card or electronic debit from a checking account. Remember your account will automatically be debited. An $11 fee is charged to cover the cost of a scheduled appointment for applicants who do not cancel/reschedule by noon on the business day prior to your scheduled appointment (Saturday noon for Monday appointments). All appointments can be canceled/rescheduled via the web without penalty if cancellation requirements are met. The $11 fee will also apply for applicants who are turned away from the printing sites due to the inability to present proper ID, who fail to present this completed Universal Fingerprint Form provided to you by your requesting agency or employer, or who are turned away because information on this form does not match the information provided during the scheduling process. You will be refunded State and Federal search fees only. Appointment scheduling is available via the web at www.bioapplicant.com/nj, 24 hours per day, 7 days per week. For applicants who do not have web access, appointments can be made by contacting us toll free at (877) 503-5981 on a first call, first served basis Monday through Friday, 8:00 AM to 5:00 PM EST and Saturday, 8:00 AM to 12 noon EST. English and Spanish speaking operators are available. Hearing impaired scheduling is available at (800) 673-0353. ONLY applicants who schedule through the call center can make payment by money order at the fingerprint site. No other form of payment is accepted at the fingerprint site. Your APPLICANT ID, Site, Date, Time of your appointment, and payment authorization will be confirmed by the call center agent or web confirmation when scheduling is complete. You must record this information in the appropriate blocks below while speaking with the operator. If you appear for fingerprinting at a site where you are not scheduled or on a different date and time, you will be turned away and not fingerprinted. If applicable, you may incur the $11 appointment fee. Your PCN number will be recorded when your fingerprinting has been completed. You MUST retain a copy of the form and a copy of the receipt provided to you by the Fingerprint Technician for your records. NO RECEIPTS WILL BE PROVIDED AFTER THE DATE OF PRINTING. Applicant ID No. Scheduled Site/ Date/ Time Agency Information #1 PYMT Authorization PCN Agency Information #2 APPLICANTS MUST NOT ALTER, SHARE, OR REUSE THIS FORM FORM NO. NJAPS2, Version 4.0 September 1, 2009 American LegalNet, Inc. www.FormsWorkFlow.com MOTOR VEHICLE COMMISSION D EALER Business Licensing Services Dealer Unit P.O. Box 171 Trenton, NJ 08666-0171 609-292-6500 ext.5014 BU SIN ESS HOUR S Business Name ____________________________________________ Business Phone __________________ Street Address _____________________________________________ Home Phone ____________________ City ____________________________________ Cell Phone ______________________ Zip ____________ E-mail Address _____________________________________________ In accordance with N.J.A.C. 13:21-15.2(j), a dealer applicant must submit a schedule of business hours (with no fewer than 20 hours per week between the hours of 9:00a.m. and 5:00 p.m., Monday through Saturday), unless it has business hours of 48 hours or more between the hours of 9:00 a.m. and 5:00 p.m., Monday through Saturday. Please check the appropriate box: A) The dealership will be open for business no fewer than 48 hours per week between the hours of 9:00AM and 5:00 PM, Monday through Saturday. Please sign below. OR B) The dealership will be open for business no fewer than 20 hours per week between the hours of 9:00 AM and 5:00 PM, Monday through Saturday. You must complete the section below to indicate the days and time your business will be open: MONDAY …………………………………………. From ____________ To ____________ TUESDAY …………………………………………. From ____________ To ____________ WEDNESDAY …………………………………………. From ____________ To ____________ THURSDAY …………………………………………. From ____________ To ____________ FRIDAY …………………………………………. From ____________ To ____________ SATURDAY …………………………………………. From ____________ To ____________ In the event that no box is checked, the dealership will be presumed to be open no fewer than 48 hours per week, between the hours of 9:00 a.m. and 5:00 p.m., Monday through Saturday. I certify that all of the information included herein is true to the best of my knowledge and belief. I am aware that, if any of this information is willfully false, I am subject to punishment. Applicant Name (Print): ________________________________________________ Title: _______________________ Applicant Signature: __________________________________________________ Date: _______________________ BLS-19 (Rev 01/08) American LegalNet, Inc. www.FormsWorkFlow.com [Not To Be Submitted by Used-Only Dealers] Motor Vehicle Commission Business Licensing Services P.O. Box 171 Trenton, New Jersey 08666-0171 MANUFACTURER'S CERTIFICATE AS TO AGENT, DISTRIBUTOR, OR AUTHORIZED DEALER This is to certify, that the undersigned is the manufacturer of motor vehicles commonly known and designated as and that (MAKE) of (STREET AND NUMBER) (FULL NAME OF DEALER) ,New Jersey, is the (AGENT, DISTRUBTOR OR AUTHORIZED DEALER) (CITY OR TOWN) of said manufacturer, and that franchise or contract of manufacturer with said dealer was made effective on , and notification of the termination or expiration thereof will be sent to the (MONTH AND DAY) (YEAR) Motor Vehicle Commission by said manufacturer. NAME OF MANUFACTURER SIGNATURE OF MANUFACTURER'S REPRESENTATIVE PRINT NAME OF MANUFACTURER'S REPRESENTATIVE ADDRESS CITY AND STATE Dealer's Reg. No. BLC-28 (R 9/07) NOTE: This certificate is to accompany application for new motor vehicle dealer's license. American LegalNet, Inc. www.FormsWorkFlow.com New Jersey Motor Vehicle Commission Business Licensing Services Bureau P.O. Box 172, Trenton, NJ 08666-0171 (888) 486-3339 ext. 5014 toll-free in NJ 609-292-6500 ext. 5014 MVC DEALER CERTIFICATION / SIGNATURE CARD SIGNATORY # 1 The undersigned Licensee hereby authorizes the person(s) whose signatures appear below to act as authorized signatory as set forth in N.J.A.C.13:21-15.1 NAME (PRINT IN FULL) ADDRESS CITY , STATE /ZIP HOME NUMBER SIGNATORY # 2 SIGNATURE NAME (PRINT IN FULL) ADDRESS CITY , STATE /ZIP HOME NUMBER SIGNATORY # 3 SIGNATURE NAME (PRINT IN FULL) ADDRESS CITY , STATE /ZIP CITY , STATE /ZIP HOME NUMBER SIGNATORY # 4 SIGNATURE NAME (PRINT IN FULL) ADDRESS HOME NUMBER SIGNATURE Pursuant to N.J.A.C. 13:21-15.5(a)4, the Chief Administrator may deny an application for a license, revoke or suspend a license after it has been granted or issue a cease and desist order to a licensee or to an unlicensed person or entity engaged in activities for which a license is required pursuant to N.J.S.A. 39:10-19 et seq., if one or more of the partners, officers, directors, other controlling persons, or employees of the applicant previously held a license issued under the authority of the Division or the Commission, which license was revoked for cause and never reissued or was suspended for cause and terms of suspension have not been satisfied, or have willfully violated a cease and desist order issued by the Chief Administrator. Pursuant to N.J.A.C. 13:21-15.5(a)7, the Chief Administrator may deny an application for a license, revoke or suspend a license after it has been granted or issue a cease and desist order to a licensee or to an unlicensed person or entity engaged in activities for which a license is required pursuant to N.J.S.A. 39:10-19 et seq., if the licensee or applicant knew or should have known that any employee, partner, officer, director, owner of a controlling interest or agent of the licensee or applicant is an individual who has been convicted of a crime arising out of fraud or misrepresentation or previously held a license issued by the Director or the Commission, which license was suspended or revoked for cause and not reissued. I have read the above regulations and certify that all of the information included herein is true to the best of my knowledge and belief. I am aware that, if any of this information is willfully false, I am subject to punishment. Business Name (Print in full): _________________________________________________________________________ License #: __________________________ Licensee Name (Print): ___________________________________________________________________________________________ Date: _________________ Licensee Signature: _________________________________________________________________________________ Title: ______________________________ (Owner, Partner or Corporate Officer) Signature card(s) must be filed for all persons authorized to act on behalf of the dealer. If you authorize any other person not listed here to execute documents or if you revoke such authority of any person listed here, you shall notify this Bureau immediately and re-submit a current signature card(s), covering all persons having authority to execute documents on half of the dealer. All signature cards prior to the most current are invalid. BLS-20 (R 10/08) American LegalNet, Inc. www.FormsWorkFlow.com