DO NOT STAPLE
Montana state authorities reserve the right to reject any form that has been altered.
MV25MDR (10/19) Page 2 of 3 This form is available in alternate formats for people with disabilities.
The renewal fee for manufactured home dealer license is $51.50 (fee includes 3% administration fee per MCA 61-3-111).
Section A: Business Information
Dealer License #
State: Zip:
State: Zip:
Business Name:
DBA Name (if applicable):
Business Street Address:
City: County:
Mailing Address:
City: County:
Business Phone Number (must be listed with directory assistance):
Federal Tax or Corporate ID Number:
Section B: Ownership Information
State the full legal name of each person who has an ownership interest in the dealership. If the licensee is a corporation,
the same information for the corporate officers must be provided, indicating capacity. Corporate officers may have day-
to-day responsibility for running the corporation. If there are additional owners or corporate officers a copy of this page
must be used. If information from a previous year has changed, form MV25MD, Manufactured Home Dealer License
Application is required. Please type or print.
Full Legal Name (as shown on your government-issued ID) Capacity
Felony Background: Has the individual listed above been found guilty of, or pled guilty to, a felony in Montana or elsewhere?
Yes_______ No _______ If yes, provide a summary of the conduct resulting in the felony determination or plea, including dates of conduct and any
court proceedings relating to conduct and name and address of court. Conduct Results:
Full Legal Name (as shown on your government-issued ID) Capacity
Felony Background: Has the individual listed above been found guilty of, or pled guilty to, a felony in Montana or elsewhere?
Yes_______ No _______ If yes, provide a summary of the conduct resulting in the felony determination or plea, including dates of conduct and any
court proceedings relating to conduct and name and address of court. Conduct Results:
Full Legal Name (as shown on your government-issued ID) Capacity
Felony Background: Has the individual listed above been found guilty of, or pled guilty to, a felony in Montana or elsewhere?
Yes_______ No _______ If yes, provide a summary of the conduct resulting in the felony determination or plea, including dates of conduct and any
court proceedings relating to conduct and name and address of court. Conduct Results:
Full Legal Name (as shown on your government-issued ID) Capacity
Felony Background: Has the individual listed above been found guilty of, or pled guilty to, a felony in Montana or elsewhere?
Yes_______ No _______ If yes, provide a summary of the conduct resulting in the felony determination or plea, including dates of conduct and any
court proceedings relating to conduct and name and address of court. Conduct Results:
Full Legal Name (as shown on your government-issued ID) Capacity
Felony Background: Has the individual listed above been found guilty of, or pled guilty to, a felony in Montana or elsewhere?
Yes_______ No _______ If yes, provide a summary of the conduct resulting in the felony determination or plea, including dates of conduct and any
court proceedings relating to conduct and name and address of court. Conduct Results:
Vehicle Services Bureau
Manufactured Home
Dealer Renewal
MVD Use Only
P.O. Box 201431, 302 N Roberts, Helena, MT 59620-1431
Phone (406) 444-3661 Fax (406) 444-0116 dojdealerinfo@mt.gov
Fax Number:
Email:
*License Liaison:
Phone Number:
Alternate Email:
*Indicate the person to act as the manufacturer/distributor/importer's point of contact in matters involving the license application or other licensing concerns.
