OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES SALVAGE MOTOR VEHICLE BUYER’S IDENTIFICATION CARD First-Fee $35.00 Duplicate Card-Fee $35.00 Replacement Renewal Sticker-Fee $35.00 Make checks payable to, “Ohio Treasurer” JOSH MANDEL FEES ARE NON-REFUNDABLE 1) Check ONLY ONE of the following: Application is for owner, partner, corporate officer, member, or trustee Application is for an employee representative. 2) PLEASE TYPE OR PRINT LEGIBLY - ALL BLANKS MUST BE COMPLETED - CHECK PAYABLE TO: “OHIO TREASURER”. JOSH MANDEL NAME LAST FIRST M.I. SOCIAL SECURITY NUMBER CITY STATE ZIP CODE HOME PHONE 3) Indicate Style of Business: Proprietorship ADDRESS BUSINESS NAME Partnership Corporation ADDRESS CITY 4) Business Trust Limited Liability PERMIT NUMBER COUNTY STATE Are you presently a licensed Ohio buyer? ZIP CODE Yes BUSINESS PHONE No If yes, indicate the Card Number: 5) All questions must be answered. If any are answered YES, give details on a separate sheet, and submit with the application. Also submit copies of journal entries, judgments, court records, or other documents related to your answer. a) Have you ever applied for a card to buy salvage motor vehicles prior to this application? Yes No If yes, give the business name, date of application, and result of application. BUSINESS NAME RESULT OF APPLICATION DATE OF APPLICATION b) Have you been the holder of a card, which was revoked or suspended? If yes, give the business name, date, and buyer’s card number. BUSINESS NAME DATE REVOKED/SUSPENDED Yes No BUYER’S CARD NUMBER c) Have you ever been convicted of or pleaded guilty to a felony or a fraudulent act in connection with dealing in salvage motor vehicles? If yes, provide details and documentation listed above. Yes No BMV 4420 4/11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 6) I affirm that I am an employee, by legal definition, and shall engage in the business of buying salvage motor vehicles for the employer indicated in this application and understand that the card becomes invalid immediately upon my termination of employment with said salvage dealership. SIGNATURE OF APPLICANT DATE X 7) I affirm that I, as proprietor, partner, officer, member, or trustee of the business entity, have authority to sign this application and will notify and surrender the buyer identification card immediately upon termination of the above applicant. SIGNATURE OF OWNER, PARTNER, OFFICER, MEMBER, OR TRUSTEE PRINT NAME OF SIGNER X TITLE OF SIGNER 8) SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , (SEAL) X NOTARY PUBLIC SIGNATURE MY COMMISSION EXPIRES , Bureau of Criminal Identification & Investigation (BCI&I) Civilian Background check is required. Ohio residence applying must be electronically fingerprinted and have the results forwarded to the Dealer Licensing Section, P.O. Box 16521, Columbus, Ohio 43216-6521. **Out-of-State applicants may submit fingerprint card, exemption form with the licensing fee and fingerprint card processing fee, along with the application for the license. Call the Dealer Licensing Section at (614) 752-7636 to obtain a fingerprint card and exemption form. Return completed application,1-2x2 passport photograph and fee to: Ohio Bureau of Motor Vehicles Attn: Dealer Licensing Section P.O. Box 16521 Columbus, Ohio 43216-6521 www.OhioAutoDealers.com BMV 4420 4/11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com .