Application For Motor Vehicle Repair Business Form - Miami-Dade County
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1
2
3Department of Regulatory and Economic Resources
Business Affairs
Consumer Protection
st
th
601 NW 1
Court, 18
Floor
Miami, Florida 33136
Tel: 786-469-2300
Fax: 786-469-2311
email:
license@miamidade.gov
140 West Flagler Street, Suite 902
Miami, Florida 33130-1561
APPLICATION FOR MOTOR VEHICLE REPAIR BUSINESS REGISTRATION
Tel (305) 375-3677 Fax (305) 375-4120
Application Type:
Check one of the following
:
Initial
Renewal
2yr Renewal
Type of Business:
Check all that apply:
Fixed Repair Facility
Mobile Repair Facility
Year/Make/Model: ______________________________
VIN: _________________________________________
TYPE OF OWNERSHIP:
Check one of the following:
Corporation
Sole Proprietor
Fictitious Name
Other ____________________
Date of Inc:_____-_____-____
D.O.B: ______-______-______
D.O.B.: _____-_____-_____
BUSINESS INFORMATION:
1.
Company Name: ___________________________________________________________________________________
2.
D/B/A:
___________________________________________________________________________________
3.
Address : _____________________________________________________________________________________
4.
Mailing Address: __________________________________________________________________________________________
5.
Phone Number: ______________ Fax Number: _______________
Cell Number __________________________________
6.
Email Address: ___________________________________ County MVR Number: ____________________
7.
Federal Tax Identification Number (FEID#): ____________________________________________________________________
OWNER/OFFICER INFORMATION:
(Please attach a separate paper for additional owners/officers)
Owner/Officer Name: ____________________________
Owner/Officer Name: _______________________________
Position:
_____________________________
Position:
_________________________________
Date of Birth:
_____________________________
Date of Birth:
__________________________________
Address & Zip Code ___________________________
Address & Zip Code _________________________________
Owner/Officer Name: ____________________________
Owner/Officer Name: ________________________________
Position:
____________________________
Position:
__________________________________
Date of Birth:
____________________________
Date of Birth:
__________________________________
Address & Zip Code ______________________
Address & Zip Code ___________________________________
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