MVDB 54 (07/10/2015)
MANUFACTURED HOME DEALER OR
WATERCRAFT TRAILER DEALER
CERTIFICATE OF REGISTRATION
APPLICATION
Purpose: Use this form to apply for a Certificate of Registration for a Manufactured Home Dealer OR Watercraft Trailer Dealer.
Instructions: Complete application and submit a copy of the valid Dealer's License with registration fee to the Motor Vehicle Dealer
Board at the above address. MVDB will send the Certificate of Registration to the business mailing address provided
below.
BUSINESS INFORMATION
CHECK APPLICABLE BOX
Manufactured Home Dealers - Include a valid Dealer's License (copy) from the Department of Housing and Community Development with this
application.
Watercraft Trailer Dealers - Include a valid Dealer's License (copy) from the Department of Game and Inland Fisheries with this application.
BUSINESS TYPE (check one)
INITIAL APPLICATION RENEWAL APPLICATION CHANGE (explain):
DEALER INFORMATION
REGISTRATION NUMBER FOR REGISTRATION ENDING (month/year)
BUSINESS NAME TRADING AS NAME
BUSINESS LOCATION ADDRESS CITY STATE ZIP CODE
BUSINESS MAILING ADDRESS CITY STATE ZIP CODE
BUSINESS OWNER'S NAME (print) (last, first, middle,suffix)
BUSINESS OWNER'S SSN BUSINESS FEDERAL TAX ID
BUSINESS OWNER'S RESIDENTIAL ADDRESS CITY OR TOWN STATE ZIP CODE
BUSINESS OWNER'S PRIMARY CONTACT NUMBER BUSINESS EMAIL ADDRESS
PRIVACY STATEMENT
In accordance with Virginia Code §§ 2.2-803, 2.2-4807 and § 58.1-520 et seq., the State Comptroller requires that this information, including your social
security number, be collected for debt set off collection purposes.
CERTIFICATION
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to MVDB are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand
that knowingly making a false statement or representation on this form is a criminal violation.
OWNER/PARTNER/OFFICER OF BUSINESS NAME (print)
OWNER/PARTNER/OFFICER OF BUSINESS NAME (signature)
DATE (mm/dd/yyyy)
MVDB USE ONLY
REGISTRATION NUMBER REGISTRATION FEE OVERPAY SHORTAGE CLERK INITIALS
www.mvdb.virginia.gov
