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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

N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date of Birth:_____________________

P r i o r N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Social Security No.:

________________

Residence Address:

_____________________________________________________________

Dealership Name:

_______________________________________________________________

Business Address:

______

________________________________________________________

Have you ever had criminal charges or civil action lodged against you in court?

_____________

If yes, please explain in writing: ___________________________________________________

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

DISCLAIMER

I hereby direct and authorize the Bureau of Criminal Identification of the Department of Attorney General for the State of Rhode Island to make available to the Rhode Island Motor Vehicle Dealers’ License & Regulation Office any criminal record that the Bureau of Criminal Identification has on file in reference to me.

I hereby waive and release any and all manner of actions, cause of actions, and demands of every kind, nature and description, arising from any release of criminal records and request therefrom, whatsoever against the State of Rhode Island, Bureau of Criminal Identification, The Attorney General and employees of the Attorney General’s Office in both law and equity Which I may now have or in the future may have.

______________________________ Signature of Applicant

Sworn to before me in the City of ____________________________ State of ____________________________ this ________ day of ________________, 20

________

______________________________ Notary Public ______________________________ Commission Expires

NOTE: Copy of photo identification with date of birth must accompany this disclaimer

DLR013 – DATED 08-25-10

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