DEALER FRANCHISE CERTIFICATION
DMV Business License Number __________________________
(If new applicant, please leave blank)
Individual/Corporate Name _____________________________________________________________________________________
DBA Name __________________________________________________________________________________________________
Mailing Address ______________________________________________________________________________________________
Street City State Zip
Physical Address _____________________________________________________________________________________________
Street City State Zip
Business Phone Number (________) ________ - ______________ FEIN _____________________________________________
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Manufacturer/Distributor Name __________________________________________________________________________________
Mailing Address ______________________________________________________________________________________________
Street City State Zip
Physical Address _____________________________________________________________________________________________
Street City State Zip
Authorized Agent ______________________________________________ Phone Number (________) ________ - ___________
Authorized Agent Address ______________________________________________________________________________________
Street City State Zip
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Vehicle Make ____________________________________ Contract Effective Date _______________________________
Assigned Sales Location _______________________________________________________________________________________
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Please check the box that applies.
This dealership is NOT establishing, relocating or reopening at a location within the relevant market area of existing
franchised dealers. Relevant market area is defined in NRS 482.3634
This dealership is establishing, relocating or reopening at a location within the relevant market area of existing franchised
dealers and proper written notice of intent to enter into this franchise agreement has been made to the department and to
each such existing franchised dealer as required by NRS 482.36357
Please check the box that applies.
A copy of the contract, including specific dealer delivery and preparation obligations, is attached for filing as required.
A blanket contract, including specific dealer delivery and preparation obligations has been or is filed as required by law.
I certify that the identified dealer and manufacturer/distributor have executed a contract effective on the date specified, subject to the
licensing provisions of Nevada Revised Statutes Chapter 482, for the representation and sales of the indicated make of motor vehicles
in the listed assigned sales location. Furthermore, I understand that pursuant to NRS 482.3638, any term or condition which waives any
provision of NRS 482.36311 – 482.36425, is void and unenforceable.
___________________________________________________
Signature of Authorized Agent Date
NOTE: In case of franchise termination or expiration, NRS 482.36352 requires written notice be given the dealer, including the effective
date and specific grounds for termination or expiration, at least 60 days prior to the effective date and that a copy of the notice be filed
with the Director of the Nevada Department of Motor Vehicles. Manufacturer and distributor responsibilities, when franchising Nevada
motor vehicle dealers, are included in NRS Chapter 482.
OBL253 (06/2013)
Occupational and Business Licensing
555 Wright Way
Carson City, Nevada 89711
(775) 684–4690
