DSD 10 (07/28/2017)
Page 2
OWNER/PARTNER/OFFICER INFORMATION
Read each question below and check the appropriate response.
A. Has any owner, partner or officer of the business ever:
1. Been refused a license or Certificate of Registration for conducting motor vehicle or trailer business or ever had this credential
suspended or revoked? ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
YES NO
2. Been convicted of a felony? .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
YES NO
3. Been convicted of a fraudulent criminal act in connection with the business of selling motor vehicles or trailers; larceny of a vehicle or
receipt or sale of a stolen vehicle, or odometer tampering or related violation? .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
YES NO
4. Committed any act or omitted any duty, which has resulted in administrative action by the Motor Vehicle Dealer Board or DMV? .... YES NO
B. Does any owner, partner or officer of the business own, operate, or control any vehicle dealership in the Commonwealth? ... .. .. .. .. .. YES NO
If the answer to any of the above questions is YES, please explain on a separate attached sheet (include names, dates, court jurisdiction and result of
administrative proceedings.)
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 DMV 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) NAME OF BUSINESS
OWNER/PARTNER/OFFICER OF BUSINESS NAME (signature)
DATE (mm/dd/yyyy)
FRANCHISE AGREEMENT INFORMATION
A sample franchise agreement or sale, service or sales and service agreement refers to a manufacturers or distributors standard franchise agreement provided to
all dealers that do not contain particularized terms, such as specific dealer's names, dealership address, dates or signatures of the parties.
Va. Code. 46.2-1569(9) requires that a franchise agreement contain the following language or words to the same effect:
If a provision herein contravenes the laws or regulations of any state or jurisdiction wherein this agreement is to be performed, or denies access to the
procedures, forums, or remedies provided to such laws or regulations, such provision shall be deemed to be modified to conform to such laws or
regulations, and all the other terms and provisions shall remain in full force, or words to that effect.
The above language, or words to the same effect, may appear in the main text or as an addendum to the franchise agreement. If an addendum is selected, the
form must contain signature lines for the parties.
LINE-MAKE(S) AND FRANCHISE DEALER(S)
LIST LINE-MAKE(S) OF VEHICLE(S) TO BE SOLD IN THE COMMONWEALTH. DO NOT LIST MODELS AS LINE-MAKE(S) (attach additional sheets if necessary)
LIST APPLICANT'S FRANCHISE DEALER(S) (attach additional sheets if necessary)
FRANCHISE DEALERSHIP DEALERSHIP LOCATION LINE-MAKE(S)
