MVDB 61 (07/01/2020)
SALESPERSON LICENSE APPLICATION
REQUEST FOR
CRIMINAL BACKGROUND CHECK
Purpose: Use this form to apply for a salesperson license or criminal background check.
Instructions: Complete sections 1, 2 and 3. Request your employing dealership to complete
section 4. Mail completed form and supporting documentation to MVDB 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 authorize the Motor Vehicle Dealer Board to conduct a criminal history inquiry solely
for the purpose of evaluating my application.
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 - CONSENT FOR CRIMINAL HISTORY CHECK
Virginia Code § 46.2-1575 lists specific circumstances under which a license for a motor vehicle dealer salesperson or dealer-operator license may be
denied. Specifically, your application for a license may be denied for having been convicted of any of the following offenses:
• Any criminal offense classified as a felony. • Larceny of a vehicle or receipt or sale of a stolen vehicle
• Any criminal act involving the business of selling vehicles. • Odometer tampering or any related violation
• Any fraudulent act in connection with the business of selling vehicles or any consumer-related fraud.
Each application will be reviewed carefully and consideration will be given to all relevant information. If you have been convicted of any of the listed
offenses, submit with your application, documentation and/or written explanation or statement concerning the convictions.
Note: 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 refused a motor vehicle dealer's or salesperson's license or had such license suspended or revoked? YES NO
B. Have you ever been convicted of a felony?* YES NO
C. Have you ever been convicted of any fraudulent or criminal act involving the business of selling motor vehicles?* YES NO
D. Have you ever been convicted of odometer tampering, larceny of a vehicle or receipt or sale of a stolen vehicle?* YES NO
* If the answer to questions B, C, or D 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 DEALER CERTIFICATION
TRADING AS NAME PRIMARY CONTACT PHONE NUMBER DEALER CERT. NUMBER
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)
LIST ANY AND ALL NAMES USED (aliases, maiden name, nicknames, etc.) CURRENT EMAIL ADDRESS
RESIDENCE STREET ADDRESS CITY STATE ZIP CODE
Non-BinaryFemaleMale
RACE EYE COLOR HAIR COLOR DMV CUSTOMER NUMBER / SSN
PLACE OF BIRTH (city/county, state, country) BIRTH DATE (mm/dd/yyyy) PRIMARY CONTACT PHONE NUMBER
GENDER (check one) WEIGHT
lbs
HEIGHT
ft. in.
1. APPLICATION TYPE
Original Renewal Transfer (attach existing license if available)
MVDB USE ONLY
Dealer Cert #
License Exp Date
License Fee
Tech Initials
Criminal Record Check Vendor (original application)
Complete if the dealer performs the criminal history check:
VENDOR NAME BACKGROUND CHECK REPORT NUMBER
