OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES APPLICATION TO DEAL IN SALVAGE MOTOR VEHICLES Indicate Type of License. Check One: Salvage Dealer Salvage Auction Salvage Pool 1) Please print legibly in black ink or type the following information: BUSINESS NAME BUSINESS TELEPHONE # DBA OR FICTITIOUS TRADE NAME, if applicable ALTERNATIVE TELEPHONE # BUSINESS STREET ADDRESS FAX # CITY STATE ZIP CODE COUNTY 2a) Vendo 2b) E-MAIL ADDRESS Federal Tax I.D. Number 3) I, as the applicant, affirm that the business listed on this application has a net worth of at least $20,000. Yes No NO applicant shall be issued a motor vehicle salvage dealer, salvage auction, or salvage pool license, or be permitted to operate under such license, unless the business maintains a NET WORTH in the sum of not less than $20,000. 4) Are you an owner, partner, or corporate officer in any other new or used dealership, motor vehicle leasing dealership, motor vehicle distributor, motor vehicle auction, motor vehicle salvage dealership, motor vehicle salvage auction, or motor Yes No vehicle salvage pool? If yes, indicate name and permit number. NAME PERMIT # NAME PERMIT # 5) Make c Josh Mandel . Fees are as follows: DO NOT SEND CASH Permit (Required) 1 @ $100.00 = Master Plate (Optional) 1 @ $50.25 = + Postage (One time postage required only if plate(s) are requested) 1 @ = + = + Additional Plates (Optional) FEES ARE NON-REFUNDABLE $2.75 @ $ 10.25 each TOTAL FEES DUE $100.00 0B You may apply for special dealer license plates to be used in conjunction with your salvage business. Ohio Revised Code Section ion may be used...on motor vehicles being transported by any persons regularly engaged in salvage operations or scrap metal processing from the point of acquisition to their established place of 1B 6) Indicate style of business: PROPRIETORSHIP BMV 4363 4/11 Page 1 of 4 PARTNERSHIP CORPORATION BUSINESS TRUST LIMITED LIABILITY American LegalNet, Inc. www.FormsWorkFlow.com 7) Check the appropriate box and complete the name, residence address, and Social Security Number in 7B: If making application as an LLC, Trust or Partnership, list each member, trustee, director or partner in 7B. Exception: if a member, trustee or partner is a corporation, please list n 7A and then list officers of the corporation in 7B. PART 7A Member-Use only if member is a corporation. Trustee-Use only if a trustee is a corporation. Partner-Use only if a partner is a corporation. CORPORATE BUSINESS NAME FEDERAL TAX ID# (EIN) ADDRESS CITY STATE ZIP CODE PART 7B Owner Partner President Trustee Director Member, (owning 10% or more) LAST NAME Partner LAST NAME Vice President MI HOME ADDRESS Trustee FIRST NAME BUSINESS NAME SSN HOME ADDRESS CITY STATE FIRST NAME MI ZIP CODE BUSINESS NAME SSN CITY STATE ZIP CODE Member, (owning 10% or more) Partner LAST NAME Secretary MI HOME ADDRESS Trustee FIRST NAME BUSINESS NAME SSN CITY STATE ZIP CODE Member, (owning 10% or more) Partner LAST NAME Treasurer MI HOME ADDRESS Trustee CITY FIRST NAME BUSINESS NAME SSN STATE ZIP CODE Member, (owning 10% or more) Ohio residents who are owners, all partners, president, all members, owning 10% or more and all trustees MUST be electronically fingerprinted and have results forwarded to the Dealer Licensing Section, P.O. Box 16521, Columbus, Ohio 43216-6521. Visit www.webcheck.ag.sate.oh.us; go to WebCheck Community, then WebCheck Community Listing for a complete listing of electronic locations in Ohio. BMV 4363 4/11 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com NOTE: Only Out-of-State applicants may submit a fingerprint card, exemption form and processing fee in lieu of having their prints electronically scanned. Please contact the Dealer Licensing Section at (614) 752-7636 to obtain a fingerprint card and an exemption form. 8) Answer each of the following questions truthfully to the best of your knowledge: OR AS OWNER, PARTNER, OFFICER, OR DIRECTOR OF A BUSINESS ENTITY: Yes No Previously applied for license to deal in motor vehicles? If yes, give business name, type of license, date and result of such application. NAME APPLIED IN TYPE OF LICENSE DATE RESULT OF APPLICATION A. B. NAME C. Ever been refused a motor vehicle salvage deal Yes No pool license, or been the holder of a license which was revoked or suspended? If yes, give business name, type of license, date and permit number. TYPE OF LICENSE DATE PERMIT NUMBER Ever been convicted of a felony? Yes No If yes, give particulars on a separate sheet and attach to this application. Ever been convicted of a fraudulent act in connection with dealing in salvage motor vehicles? If yes, give particulars on a separate sheet and attach to this application. Yes No NOTE: Any felony conviction or any misdemeanor conviction related to dealing in salvage motor vehicles is reason for the Bureau of Motor Vehicles to DENY the application. Yes No 9) Are you or do you intend on sharing the proposed business location with another licensed dealer? If yes, indicate the business name and, if available, the permit number of the other dealer. (See note below) NAME PERMIT NUMBER NOTE: A certificate of compliance form, BMV 4347, must be submitted with this application, if you answered YES to the above question. 10) Was the proposed business location previously occupied by another licensed dealer? If yes, give the business name, if available. Yes No BUSINESS NAME YOU WILL LOSE YOUR DRIVER LICENSE FOR AT LEAST 90 DAYS IF YOU DRIVE WITHOUT INSURANCE OR OTHER ACCEPTABLE FINANCIAL RESPONSIBILITY COVERAGE In Ohio, it is illegal to drive any motor vehicle without insurance or other financial responsibility (FR) coverage. It is also illegal for any motor vehicle owner to allow anyone els PROOF OF COVERAGE IS REQUIRED: Whenever a police officer issues a traffic ticket At all vehicle inspection stops Upon traffic court appearances and Upon random checks by the Registrar of Motor Vehicles. ANY DRIVER OR OWNER WHO FAILS TO SHOW PROOF OF INSURANCE OR OTHER COVERAGE WILL: Lose his or her driver license for 90 DAYS on first offense, ONE YEAR on second offense and TWO YEARS on additional offenses Lose his or her license plates and vehicle registration Pay reinstatement fees of $100.00 for first offense, $300.00 for second offense, $600.00 for third and subsequent offenses Pay a $50.00 penalty for any failure to surrender his or her driver license, license plates, or registration AND YEARS. ONCE THIS SUSPENSION IS IN EFFECT: Any driver or owner who violates the suspension will have his or her vehicle immobilized and his or her license plates confiscated for at least 30 DAYS first offense and 60 DAYS second offense. For third or subsequent offenses, the vehicle will be forfeited and sold and the person will not be permitted to register any motor vehicle in Ohio for FIVE YEARS. IF YOU ARE INVOLVED IN AN ACCIDENT WITHOUT INSURANCE OR OTHER FR COVERAGE: In addition to all the penalties listed above, you may have A SECURITY SUSPENSION for TWO YEARS or more and A JUDGMENT SUSPENSION INDEFINITELY (until all damages have been satisfied). THESE PENALTIES ARE IN ADDITION TO ANY FINES OR PENALTIES IMPOSED BY A COURT OF LAW. WARNING: THESE LAWS DO NOT PREVENT THE POSSIBILITY THAT YOU MAY BE INVOLVED IN AN ACCIDENT WITH A PERSON WHO HAS NO INSURANCE OR OTHER FR COVERAGE. WHEN REQUIRED, PROOF OF COVERAGE MAY BE SHOWN BY ANY OF THE FOLLOWING: AN INSURANCE POLICY showing automobile liability insurance of at least $12,500 bodily injury per person, $25,000 injury two or more persons, and $7,500 property damage AN INSURANCE IDENTIFICATION CARD (same coverage) A SURETY BOND OF $30,000 issued by any authorized surety company or insurance company A BMV BOND SECURED BY REAL ESTATE having equity of at least $60,000 A BMV CERTIFICATE FOR MONEY OR GOVERNMENT BONDS in the amount of $30,000 on deposit with the Ohio Treasurer of State A BMV CERTIFICATE OF SELF-INSURANCE, available only to companies or persons who own at least twenty-six motor vehicles. American LegalNet, Inc. www.FormsWorkFlow.com BMV 4363 4/11 Page 3 of 4 I affirm that the motor vehicles owned by this business will be insured or have other FR coverage, will not be operated without FR coverage and will not be used as commercial vehicles unless so registered. (This statement only applies to applicants that order license plates.) I also affirm that all statements in the foregoing application and in any attached sheets are true and correct and that I, as proprietor, as a partner, an officer, member, or trustee, have authority to sign this application and to make the statements contained herein. I understand that a false statement, in the application, is reason for which this application shall be denied. X DATE OF APPLICATION SIGNATURE (OWNER, PARTNER, OFFICER, MEMBER, OR TRUSTEE) TITLE PRINT OR TYPE NAME OF SIGNER NOTARY: Subscribed and sworn to before me this (SEAL) My commission expires day of , in the county of State of Ohio. X INCOMPLETE INFORMATION WILL RESULT IN A DELAY IN PROCESSING THE APPLICATION. Upon receipt of the completed application, other supporting documents, photos, and fee, a request for inspection of the proposed location will be requested. Please allow four to six weeks. RETURN THE COMPLETED APPLICATION, PHOTOGRAPHS, OTHER SUPPORTING DOCUMENTS AND FEES TO: The Ohio Bureau of Motor Vehicles, Attn: Dealer Licensing Section, P.O. Box 16521, Columbus, Ohio, 43216-6521. www.OhioAutoDealers.com American LegalNet, Inc. www.FormsWorkFlow.com BMV 4363 4/11 Page 4 of 4