Form D-17a - Application For A Vehicle Dealer License
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3KANSAS DEPARTMENT OF REVENUE
DIVISION OF VEHICLES
F#_____________
TOPEKA, KANSAS 66626-0001
PH # 785-296-3621
D-_____________
62
APPLICATION FOR A VEHICLE DEALER LICENSE
1st Auto/MC Tag Fee AU MCL
$ 275.50
Check type of dealer license that is being applied for (one license per application):
New/Used Vehicle Dealer
$75.00
Distributor
$75.00
Addt’l Auto Plate(s)
@ $25.50 ea. $
Used Vehicle Dealer
$75.00
Distributor Branch
$75.00
Addt’l MC Plate(s)
@ $25.50 ea. $
Salvage Vehicle Dealer
$75.00
Factory Branch
$75.00
Mfg. Home Plate(s)
@ $25.50 ea. $
Wholesale Vehicle Dealer
$75.00
Lending Agency
$50.00
Trailer Plate(s)
@ $25.50 ea. $
Plate Subtotal
$
Auction Motor Vehicle Dealer $75.00
Used RV Broker
$75.00
Full Use Plate(s)
@ $350.50 ea. $
Insurance Company
$75.00
Vehicle Crusher
$75.00
Supplemental Location Fee $35.00
$
Salvage Pool
$75.00
Vehicle Recycler
$75.00
License Fee
$
st
nd
1
/2
Stage Manufacturer
$225.00
Rebuilder
$75.00
TOTAL FEE DUE
$
st
nd
1
/2
Stage Convertor
$50.00
Scrap Metal Recycler $75.00
1. NAME OF BUSINESS
DBA (if applicable)
BUSINESS ADDRESS
CITY
COUNTY
STATE
ZIP
*BUSINESS PHONE
FAX
CELL PHONE
(Your business phone must be in the business name and listed with the phone company)
Email Address
SALES TAX ID #:
FEIN:
(Copy of Kansas Sales Tax Certificate must be attached)
2. Please mark appropriate type of business (entity). If you are an out of state corporation please contact the Kansas Secretary of State’s
Corporation Office at 785-296-4564 to register as a Foreign Corporation with the State of Kansas.
*Must attach a copy of Secretary of State’s registration papers.
Individual
Partnership
Corporation*
Limited Liability Co.*
(Sole Proprietor)
LTD Company*
Limited Liability Partnership*
Date Incorporated/Registered & State
N/A
Copy of Secretary of State Papers is enclosed.
3. If your entity type is Individual or Partnership you are required to submit three credit references. The credit references must be on their
N/A
business letterhead.
Copy of three credit references are enclosed.
4. Please complete the below information for each owner(s) of your business. When a corporation is owned by more than 20
stockholders, such corporation may list the President, Vice President, Secretary and Treasurer.
THE BELOW OWNER/CORPORATE OFFICER INFORMATION IS REQUIRED.
Name
(Complete Legal Name)
Residence Address, City, ST, Zip
Residence Ph.#
Birth Date
SSN
Sex
P
P
LEASE
RINT
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