Form D-43b - License Transfer Application For Manufactured Home Salesperson, Factory Representative Or Distributor Representative

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KANSAS DEPARTMENT OF REVENUE
Transfer Fee
DIVISION OF VEHICLES
DEALER LICENSING BUREAU
Folder #
DOCKING STATE OFFICE BUILDING
TOPEKA, KANSAS 66626-0001
Dealer #
(785) 296-3621 Fax (785) 296-5854
LICENSE TRANSFER APPLICATION FOR MANUFACTURED HOME
SALESPERSON, FACTORY REPRESENTATIVE OR DISTRIBUTOR REPRESENTATIVE
1.
2.
Social Security Number
Applicants Last Name
First Name
M.I.
3.
Applicants Home Street Address
City
Co
State
Zip Code
4.
5.
Applicants Home Phone Number
Drivers License Number
State/Issued
6.
7. Sex:
Date of Birth
8.
I REQUEST THE FOLLOWING LICENSE:
9
.
MUST BE COMPLETED BY FORMER EMPLOYER
F#
The above named applicant is no longer employed by my dealership. I have either attached their certificate to this transfer application or
have returned the original copy of said employee’s license certificate to the Division of Vehicles.
D#
Business Phone Number
Dealer Business Name
Dealer Business Address
Street
City
County
State
Zip
Signature of Owner or Authorized Representative& Title
Date
10
.
TO BE COMPLETED BY NEW EMPLOYER
F#
I certify that the above mentioned applicant is now employed by my dealership and I have the authority to sign his transfer application as
proprietor, partner, corporate officer or general manager.
D#
Business Phone Number
Dealer Business Name
Dealer Business Address
Street
City
County
State
Zip
Signature of Owner or Authorized Representative& Title
Date
Applicant’s Hand Printed Name
Applicants Signature
Date
D-43b (Rev. 053/07)

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