Form Dr 2115 - Motor Vehicle Salesperson License Application

DR 2115 (05/99)

COLORADO DEPARTMENT OF REVENUE

AUTO INDUSTRY LICENSING DIVISION

MOTOR VEHICLE SALESPERSON

DENVER CO 80261-0016

(303) 205-5604

LICENSE APPLICATION

Instructions: Provide an answer(s) to each question. Attach Examination Affidavit, License Fee and $5000 bond. Use additional paper if necessary

to provide complete information. False statements or omissions may result in denial or disciplinary action.

PERSONAL INFORMATION

1. Check One.

Original Application

Renewal

Additional Licenses

FOR A RENEWAL OR AN ADDITIONAL LICENSE, SKIP QUESTIONS 4, 5 & 6.

2. Name

Social Security Number

Date of Birth

(last, first & middle)

3. Home Address

City

State

ZIP

Home Phone

Yes

Have you ever been employed in the automobile industry? If "Yes," list below.

DATE

EMPLOYER

ADDRESS

STATE

POSITION

FROM/TO

BACKGROUND INFORMATION

Yes

Have you had any professional or occupational license, including a dealer or salesperson, denied or subjected to disciplinary action,

such as suspension, revocation, probation, fine, etc. in the last 10 years? If you answered "Yes", provide the following information.

DATE

STATE

NATURE OF VIOLATION/CHARGE

LICENSE OCCUPATION

DISPOSITION

Yes

Have you been arrested, charged with, convicted of or pled no contest to any felony or misdemeanor crime in the past 10 years?

If "Yes", give full details below, including: type (felony/misdemeanor), charges, offense details, date and location of conviction, sentence received, current status

(released, probation, parole), etc. Please attach additional pages if needed and have employer sign all pages. You must also attach copies of all final court

judgments for those convictions. If you are currently on probation or parole, attach a status letter from your probation/parole officer.

LOCATION

DATE

OFFENSE

SENTENCE

STATUS

CITY, COUNTY, STATE

STATEMENT OF UNDERSTANDING

I declare under penalty of perjury in the second degree that the statements made on this application are true and complete to the best of my knowledge.

Any false answer or statement made constitutes second degree perjury. I hereby appoint the Executive Secretary of the Motor Vehicle Dealer Board as

my true and lawful agent for the service of process in accordance with 12-6-115(6) C.R.S. I hereby authorize the release to board agents of any and all records

pertaining to my employment and criminal background.

I understand that the salesperson license issued is only TEMPORARY and is subject to denial pending the results of the Dealer Board investigation of my

background. The TEMPORARY status is in effect unless I receive a Notice of Denial. Upon receipt of a Notice of Denial, I agree to immediately surrender

my salesperson license to the Dealer Board. I understand that a denial of my license is effective immediately. I realize that I may appeal the denial of my

license application and that until a determination is made of that appeal, I will not possess a salesperson license. If I do not receive a Notice of Denial, my

salesperson license is valid for 12 months and expires on the date printed on the license.

Signature

Date

EMPLOYING DEALER'S CERTIFICATION

I hereby certify that I have reviewed the information provided above and agree to employ the applicant as a motor vehicle salesperson under the dealer license

number provided.

Dealer License Name/DBA

Dealer’s License No.

Business Phone

Address

Signature

Printed Name

Title

(dealer owner, corporate officer, LLC manager, or general manager)

Corporate Officer

Owner

General Manager