DSD 7 (01/10/2017)
MANUFACTURER OR DISTRIBUTOR
REPRESENTATIVE LICENSE APPLICATION
Purpose: Use this form to apply for a manufacturer or distributor representative license.
Instructions: Complete sections 1, 2 and 3. Request your employing company to complete section 4. Mail completed form and
supporting documentation to DMV at the above address.
APPLICANT NAME (print)
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
I understand that untruthful or misleading answers are cause for denial of the application. I further understand that it is unlawful to knowingly make a false
statement and any violation may be prosecuted to the full extent of the law.
I certify and affirm that all the information presented in this form is true and correct. 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.
3. APPLICANT CERTIFICATION
Each application will be reviewed carefully and consideration will be given to all relevant information. If you have been convicted of any offenses, you
are advised to submit with your application documentation and/or written explanation or statement concerning the convictions. You should include
attested copies of your convictions and if you have been released from probation/parole, evidence of this fact.
A. Have you ever been convicted of a felony?* YES NO
B. Have you ever been convicted of any fraudulent or criminal act involving the business of selling motor vehicles?* YES NO
C. Have you ever been convicted of odometer tampering, larceny of a vehicle or receipt or sales of a stolen vehicle?* YES NO
* If the answer to questions A, B, or C is YES, attach a copy of conviction record(s), name of probation officer, date(s), and court jurisdiction(s).
PRIVACY NOTICE: In accordance with Virginia Code §§ 2.2-803 and 2.2-4800, et al., the State Comptroller requires that this information, including your social
security number, be collected for debt set off collection purposes.
BUSINESS STREET ADDRESS CITY STATE ZIP CODE
4. EMPLOYING COMPANY CERTIFICATION
BUSINESS NAME TRADING AS NAME
I certify that the applicant named herein is employed by the firm as a salesperson or representative and is not an independent contractor. If application is for a
salesperson's license, I certify the applicant is not employed by another dealer unless the dealerships are owned by the same person, partnership or corporation.
I certify and affirm that all the information presented in this form is true and correct. 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 NAME (print)
OWNER / PARTNER / OFFICER SIGNATURE
DATE (mm/dd/yyyy)
2. APPLICANT INFORMATION
FULL LEGAL NAME (last) (first) (middle) (suffix)
RESIDENCE STREET ADDRESS CITY STATE ZIP CODE
RACE EYE COLOR HAIR COLOR SOCIAL SECURITY NUMBER
PLACE OF BIRTH (town, city, state, country) BIRTH DATE (mm/dd/yyyy) PRIMARY CONTACT PHONE NUMBER
LIST ANY AND ALL NAMES USED (aliases, maiden name, nicknames, etc.)
GENDER (check one)
Male Female
WEIGHT
.lbs
HEIGHT
ft. in.
Are you currently licensed by the Motor Vehicle Dealer Board? Yes No
IF YES, PROVIDE DEALER NUMBER
1. APPLICATION TYPE
Original Renewal Transfer (attach existing license if available)
DMV USE ONLY
LICENSE FEE ______________
LOG NUMBER ______________
DEALER CERT. NUMBER REP LICENSE NUMBER LICENSE YEAR ENDING
