List the names of all owners, officers, board members, governors, and five percent and greater shareholders. Company names are not
acceptable. If you require more room, please provide information on a separate sheet and attach to this application.
DEALER OWNERSHIP INFORMATION - Please print or type.
Each person named on this application must sign.
1.
X
Subscribed and sworn to before me this
day of _______ 20 _____
NOTARY PUBLIC
COUNTY:
MY COMISSION EXPIRES:
Subscribed and sworn to before me this
day of _______ 20 _____
NOTARY PUBLIC
COUNTY:
MY COMISSION EXPIRES:
Subscribed and sworn to before me this
day of _______ 20 _____
NOTARY PUBLIC
COUNTY:
MY COMISSION EXPIRES:
2.
X
3.
X
DEALER OWNERSHIP HISTORY
If you answer yes to questions one and two, please attach a separate statement to this application that includes the name of the person
convicted, date of conviction, and state and county where the conviction took place.
1. Has anyone named on this application been enjoined or convicted of violating any of the following within the last ten years:
• Consumer Fraud in Sales - Minnesota Statutes, section 325F.69
• Odometer Tampering - Minnesota Statutes, sections 325E.14, 15, 16, or United States Code, title 15
• Receiving or Selling Stolen Vehicles - Minnesota Statutes, section 609.53
Yes No
2. Has anyone named on this application pleaded guilty, entered a plea of nolo contendere or no contest, or been found guilty
in a court of competent jurisdiction of any charge of failure to pay state or federal income or sales taxes, or felony charge of
forgery, embezzlement, obtaining money under false pretenses, theft by swindle, extortion, conspiracy to defraud, or
bribery within the last ten years?
Yes
No
3. Has anyone named on this application applied for or held a Minnesota dealer's license in the past?
Yes
No
Name of person who applied for or held license:
Name of dealership and license number:
When was the dealership last licensed:
Was the license ever canceled, denied, suspended, or revoked?
Yes (explain below) No
Dealer License Ownership Change
PS2401-15 (11/19)
1.) Full Name:
Date of Birth (mm/dd/yyyy)
Driver's License Number:
State:
Position with Dealership:
2.) Full Name:
Date of Birth (mm/dd/yyyy)
Driver's License Number:
State:
Position with Dealership:
3.) Full Name:
Date of Birth (mm/dd/yyyy)
Driver's License Number:
State:
Position with Dealership:
Social Security Number:
Social Security Number:
Social Security Number:
List Previously Used Names:
List Previously Used Names:
List Previously Used Names:
