MVDB 10 (07/01/2019)
10. CERTIFICATION. Read and certify by printing and signing below.
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 THE BUSINESS NAME (print) NAME OF BUSINESS
DATE (mm/dd/yyyy)OWNER, PARTNER, OFFICER OF THE BUSINESS SIGNATURE
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.
8. FRANCHISED DEALERS ONLY List name and address of individual awarded franchise(s) or sales agreement(s). Use additional sheet(s),
if necessary, and attach.
NAME
ADDRESS CITY STATE ZIP CODE
9. READ EACH QUESTION BELOW AND CHECK THE APPROPRIATE RESPONSE
YES NO
A.
Has any owner, partner, officer or Dealer-Operator of business ever been refused a Motor Vehicle Dealer's
License or Certificate of Registration or has his/her license or certificate suspended or revoked?
B.
Has any owner, partner, officer or Dealer-Operator of business ever been convicted of a felony?
C.
Has any owner, partner, officer or Dealer-Operator of business ever been convicted of any fraudulent or criminal act
in connection with the business of selling motor vehicles?
D.
Has any owner, partner, officer or Dealer-Operator of business ever been convicted of larceny of a vehicle OR
receipt or sale of a stolen vehicle?
E.
Has any owner, partner, officer or Dealer-Operator of business ever been convicted of odometer tampering or any
related violation?
F.
Has any owner, partner, officer or Dealer-Operator committed any act or omitted any duty, with the result being
administrative action taken by the Board or DMV?
G.
If the answer to any of the above questions is YES, please explain on a separate sheet (include names, dates, court
jurisdictions and result of administrative proceedings).
H.
Are all salespersons employees of the dealership (issued a W-2) and not independent contractors (issued a 1099)?
I.
Is any owner, partner, officer or Dealer-Operator applying to be, required to be, or currently licensed as a
vehicle manufacturer, factory branch, distributor, distributor branch, or subsidiary thereof in the
Commonwealth? If YES, indicate Dealer Certificate Number:
7. FRANCHISED DEALERS ONLY Attach a copy of the Franchise and service agreement with manufacturer or distributor if this is an initial application.
Only list line-makes of vehicles to be sold in this state. DO NOT list models as line-makes. Use additional sheet(s), if necessary, and attach.
MANUFACTURER ADDRESS LINE-MAKES
