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APPLICATION FOR DEALERS LICENSE

STATE OF RHODE ISLAND ‐‐ DIVISION OF MOTOR VEHICLES Dealer Section 600 New London Avenue ,Cranston, RI 02920-3024 www.dmv.ri.gov

DEALERS’ EMPLOYEE AUTHORIZATION

Dealership Licensed Name:

_______________________________________________

Business Address:

________________________________________________________

Authorization Number:

________________

The following people, including owner, partner and corporate officer, are properly authorized to pick up 20-Day Temporary Plates, Loaner Agreement Forms and other forms as allowed by the Department of Motor Vehicles for the above named dealership.

Name

Drivers’ License Number

1.

________________________________________________________________________________

2.

________________________________________________________________________________

3.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

It is understood that every dealership is entitled to list a maximum of three (3) employees who are noted on the Employee List receiving a W-2 form. You must contact the Dealers’ License & Regulations office if you must make any changes to this list.

NOTE: This is not an authorization to register vehicles in the Dealers’ Room.

_____________________________________ Signature of Owner, Partner or Corporate Office

______________________________________ Print Name

State of Rhode Island

C o u n t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Subscribed and sworn to before me this

_______day of

20

_____________ _____

_________________________________ Notary Public

______________________________ Commission Expires

DLR013 – DATED 08-25-10

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