Fillable MOTOR VEHICLE REPAIR REGISTRATION APPLICATION (Florida Department of Agriculture and Consumer Services)

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MOTOR VEHICLE REPAIR REGISTRATION APPLICATION (Florida Department of Agriculture and Consumer Services)

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The MOTOR VEHICLE REPAIR REGISTRATION APPLICATION (Florida Department of Agriculture and Consumer Services) form is 3 pages long and contains:

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  • 19 check-boxes
  • 59 other fields

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File type: PDF

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BROWSE FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES FORMS

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MOTOR VEHICLE REPAIR
REGISTRATION APPLICATION
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Make Non-Refundable Check or
Money Order payable to FDACS and
remit with application to:
FDACS
Section 559.904, Florida Statutes
P.O. Box 6700
Rule 5J-12.002, Florida Administrative Code
Tallahassee, FL 32314-6700
NICOLE “NIKKI” FRIED
1-800-HELP-FLA (435-7352) • (850) 410-3800
COMMISSIONER
www.FDACS.gov • (850) 410-3804 Fax
All documents and attachments submitted with this application may be subject to public review pursuant to Chapter 119, F.S.
PLEASE TYPE OR PRINT.
Business Information
Please Select one:
New Filing
Change of Owner:
(If you have recently purchased an existing motor
Previous MV#
MV#
DTN#
vehicle repair shop, please check both boxes)
1.
Business Name (as registered with the Florida Department of State, Division of Corporations):
2.
Fictitious (DBA) Name (as registered with the Florida Department of State, Division of Corporations):
3.
Form of Organization:
Sole Proprietorship
Corporation
Limited Liability Partnership
Limited Liability Company
Partnership
Other
(please describe)
:
4.
Business Street Address (include APT or SUITE # in all address lines):
City:
State:
Zip Code:
-
Mailing Address (if different from above):
City:
State:
Zip Code:
-
Telephone Number:
( ) -
Fax Number:
( ) -
Email Address*:
Website:
* Future correspondence may be electronic, so please ensure the provided email address is accurate and valid.
F&A Use Only
Motor Vehicle Repair
Org Code: 42 10 06 25 000
EO: A2
Object Code: 001161
$100/$300/$600
FDACS–10900 Rev. 04/19
Page 1 of 3
5.
Federal Employer ID Number (FEIN):
-
6.
Enter the name and address of the individual owner, or all general partners, or all corporate officers and directors.
(Attach additional copies as needed using the same format) [s. 559.904(10), F.S.]
Name:
Title:
Address:
City:
Telephone Number:
( ) -
State:
Zip Code:
-
Name:
Title:
Address:
City:
Telephone Number:
( ) -
State:
Zip Code:
-
7.
Check Yes or No for each response. If Yes, provide on a separate sheet, the name of such person, the nature of the
offense, the court having jurisdiction, the disposition of the offense, the date of disposition,
and any other pertinent
information. Have
any persons listed in question #6:
Yes
No
Failed to satisfy a civil fine, administrative fine, or other penalty arising out of any administrative or
enforcement action brought by any governmental agency based upon conduct involving fraud or dishonest
dealing, or any violation of the Florida Motor Vehicle Repair Act;
Yes
No
Had against them any civil, criminal, or administrative adjudication in any jurisdiction within the last five (5)
years based upon conduct involving fraud, dishonest dealing, or any violation of the Florida Motor Vehicle
Repair Act;
Yes
No
Had a judgment entered against them within the last five (5) years in any action brought by the department
or the state attorney pursuant to the Florida Deceptive and Unfair Trade Practices Act or the Florida Motor
Vehicle Repair Act.
Additional Requirements
8.
Please submit copies of all licenses, permits, and certifications obtained by the applicant or employees of the applicant.
[s. 559.904(1)(d), F.S.]
Number of employees which the applicant intends to employ or which are currently employed.
[s. 559.904(1)(e), F.S.]
9.
10.
A copy of your Estimate and Invoice Forms. [s. 559.904(4), F.S.] For renewals, you must send in a copy of your Estimate and
Invoice Form if the original form filed by the applicant has been changed, altered, or revised. See the Estimate and
Invoice Requirements for statutorily required provisions and sample Estimate and Invoice forms at
https://www.FDACS.gov/Business-Services/Motor-Vehicle-Repair.
FDACS–10900 Rev. 04/19
Page 2 of 3
Fees
Preparer Information
Application Certification
11.
NO FEE IS REQUIRED
if your repair shop is located in BROWARD COUNTY or MIAMI-DADE COUNTY
or your shop is
a licensed
MOTOR VEHICLE DEALER and you provide the following:
BROWARD COUNTY
shops must attach a copy of their current Broward AR or AB license to this application
. There are
____ individuals who perform repairs at this location.
MIAMI
-DADE COUNTY shops must attach a copy of their current Miami-Dade MVR registration to this application.
There
are ____ individuals who perform repairs at this location.
MOTOR VEHICLE DEALERS licensed by the Florida Department of Highway Safety and Motor Vehicles must attach a
copy of their current DHSMV license to this application.
IF YOU ARE UNABLE TO ATTACH A CURRENT COPY OF YOUR LICENSE OR CERTIFICATE
YOU MUST USE THE FEE SCHEDULE LISTED BELOW.
12.
Biennial Registration Fee Schedule. Select one.
1
– 5 individuals who perform repairs at this location
$100 for two year registration
6
– 10 individuals who perform repairs at this location
$300 for two year registration
11 or more individuals who perform repairs at this location
$600 for two year registration
NOTE: Active duty military, honorably discharged veterans, military spouses or surviving spouses may be eligible for a waiver of
the registration fee. See section 559.904(3), Florida Statutes, and rule 5J-12.002, Florida Administrative Code for eligibility
requirements.
Prepared By (please print name):
Title of Preparer:
Telephone Number of Preparer:
( ) -
I am empowered to execute this application on behalf of the above named entity or individual.
Print Name of Applicant
Title and Phone Number
Signature of Applicant
Date
FDACS–10900 Rev. 04/19
Page 3 of 3
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MOTOR VEHICLE REPAIR REGISTRATION APPLICATION (Florida Department of Agriculture and Consumer Services)

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Completed 22 September 2021

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