FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES ADAM H
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FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES ADAM H

PUTNAM COMMISSIONER MOTOR VEHICLE REPAIR REGISTRATION PACKAGE VV573615736857368573725736157372573635736457347575215734757368573685737257361573725736557365573645735957347ORULGD573476WDWXWHV 57368 brPage 2

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FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES ADAM H




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FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES ADAM H. PUTNAM COMMISSIONER MOTOR VEHICLE REPAIR REGISTRATION PACKAGE VV)ORULGD6WDWXWHV -
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'$&65HY 3DJH ,, RI,,, )ORULGD'HSDUWPHQWRI$JULFXOWXUHDQG&RQVXPHU6HUYLFHV Motor Vehicle Repair

Registration Package Table of Contents 7DEOHRI&RQWHQWV 3DJH, ,QLWLDO$SSOLFDWLRQ&KHFNOLVW 3DJH ,, 5HJLVWUDWLRQ$SSOLFDWLRQ 3DJH
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'$&65HY 3DJH ,,, RI,,, APPLICATION CHECKLIS T AND INSTRUCTIONS

3OHDVHUHYLHZWKHIROORZLQJDQGFKHFNRIILWHPVDSSURSULDWHWR\RXURSHUDWLRQ,WHPVQRWDSSURSULDWHVKRXOGEHPDUNHG1$ )DLOXUHWRVXEPLWDOORIWKHUHTXLUHGLQIRUPDWLRQZLOOGHOD\SURFHVVLQJRI\RXUDSSOLFDWLRQ

'212786(7+,6)250LI\RXDUHUHQHZLQJ\RXUUHJLVWUDWLRQ,I\RXDUHUHQHZLQJ\RXUUHJLVWUDWLRQDQGKDYHQRWUHFHLYHG DQDSSOLFDWLRQE\PDLOSOHDVHFRQWDFWXVDW +(/3)/$FDOOLQJIURPZLWKLQ)ORULGDRU FDOOLQJ

IURPRXWVLGHRI)ORULGDRUDFFHVVWKHRQOLQHUHQHZDODSSOLFDWLRQDWZZZKHOSIODFRPUHJLVWHURQOLQH 3ULRUWR any UHSDLURUDWWHPSWHGUHSDLU0RWRU9HKLFOHUHSDLUVKRSVPXVWVXEPLWDOORIWKHIROORZLQJWKDWDSSO\WKHVHLWHPVPXVW EHVXEPLWWHG with WKHUHJLVWUDWLRQDSSOLFDWLRQ and

ZKHQDQ\FKDQJHVRFFXU ,VWKHDSSOLFDWLRQIRUPILOOHGRXWFRPSOHWHO\" (mus t include authorized signature) ,VWKHFRUUHFWUHJLVWUDWLRQIHHHQFORVHG" VHHSDJH 'LG\RXDWWDFKDFRS\RI\RXUHVWLPDWHDQGLQYRLFHIRUPVWRWKHUHJLVWUDWLRQDSSOLFDWLRQ" $ VDPSOH

HVWLPDWHDQGLQYRLFHIRUPLVDYDLODEOHDWZZZKHOSIODFRPPYUBEXVLQHVVKWPO ,I\RXKDYHDGGLWLRQDOORFDWLRQV\RXPXVWVXEPLWDVHSDUDWHDSSOLFDWLRQIRUHDFKORFDWLRQ Once your completed application has been approved, the Department will issue you a two (2) year registration to operate as a motor vehicle repair shop. You will be notified by the Department when it is time to renew your registration.


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'$&65HY 3DJHRI )ORULGD'HSDUWPHQWRI$JULFXOWXUHDQG&RQVXPHU6HUYLFHV 'LYLVLRQRI&RQVXPHU6HUYLFHV ADAM H. PUTNAM COMMISSIONER MOTOR VEHICLE REPAIR REGISTRATION APPLICATION V)ORULGD6WDWXWHV - +(/3 )/$ alling Outside Florida ZZZKHOSIODFRP Fax

$OOGRFXPHQWVDQGDWWDFKPHQWVVXEPLWWHGZLWKWKLVVWDWHPHQWDUHVXEMHFWWRSXEOLFUHYLHZSXUVXDQWWR&KDSWHU)6 '2 12786(7+,6)250LI\RXDUHUHQHZLQJ\RXUUHJLVWUDWLRQ,I\RXDUHUHQHZLQJ\RXUUHJLVWUDWLRQDQGKDYHQRWUHFHLYHGDQ

DSSOLFDWLRQE\PDLOSOHDVHFRQWDFWXVDW+(/3)/$FDOOLQJIURPZLWKLQ)ORULGDRU FDOOLQJIURP RXWVLGHRI)ORULGD Please allow adequate time for the processing of your application. )DLOXUHWRVXEPLWDOORIWKHUHTXLUHG

LQIRUPDWLRQZLOOGHOD\SURFHVVLQJRI\RXUDSSOLFDWLRQ All fees are non-refundable. Business Information Please Select one: 1HZ)LOLQJ &KDQJHRI2ZQHU 1. Name of Motor Vehicle Repair Shop 2. Business Street Address (include APT or SUITE # in all address lines) City: State: Zip Code: Mailing Address (if different from above) City: State: Zip Code: 3. Business Telephone Number: Fax Number: Email Address*: Website: * Future correspondence may be electronic; please ensure the provided email address is accurate and valid. 4. Federal

Employer ID Number 5. Ownership / Form of Organization, PLEASE CHECK ONE. Corporation Legal Name, as registered with the Florida Department of State) LLC Legal Name, as registered with the Florida Department of State) Partnership Legal Name, as registered with the Florida Department of State Sole Proprietorship (Provide Name of Owner) Make check or money or der payable and remit application to )'$&6 32%R[ 7DOODKDVVHH)/ 0RWRU9HKLFOH5HSDLU 2UJ&RGH (2 $ 2EMHFW&RGH
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'$&65HY 3DJHRI Physical Street Address (include APT or SUITE # in all address lines) City: State: Zip Code: Mailing Address (if different from above) City: State: Zip Code: 6. (QWHUWKHQDPHDQGDGGUHVVRIWK HLQGLYLGXDORZQHU RUDOO JHQHUDO SDUWQHUV RU DOO FRUSRUDWHRIILFHUVGLUHFWRUVDQG UHJLVWHUHGDJHQWV

,QGLFDWHZKHWKHUDQ\RIWKHLQGLYLGXDOVOLVWHGEHORZ Attach additional copies as needed [s. 559.904(10), F.S.] DYHEHHQ adjudicated guilty RI DQ\FULPH RUIRXQGJXLOW\LQDQ\FLYLORUDGPLQLVWUDWLYHDFWLRQLQDQ\MXULVGLFWLRQ EDVHGXSRQFRQGXFW

LQYROYLQJIUDXGGLVKRQHVWGHDOLQJRUDQ\YLRODWLRQRIWKH0RWRU9HKLFOH5HSDLU$FW +DYHQRWVDWLVILHGDFLYLORUDGPLQLVWUDWLYHILQHRURWKHUS HQDOW\DULVLQJRXWRIDQ\DFWLRQEURXJKWE\D

JRYHUQPHQWDODJHQF\EDVHGXSRQFRQGXFWLQYROYLQJIUDXGGLVKRQHVWGHDOLQJRUDQ\YLRODWLRQRIWKH0RWRU9HKLFOH 5HSDLU$FW $UHVXEMHFWWRDMXGJPHQWHQWHUHGDJDLQVWWKHPLQDQ\DFWLRQEURXJKWXQGHUWKH)ORU LGD'HFHSWLYH DQG8QIDLU 7UDGH 3UDFWLFHV$FW &KHFN YES RU NO IRUHDFKUHVSRQVH

,I\HVSURYLGHRQDVHSDUDWHVKHHWWKHQDPHRIVXFKSHUVRQWKHQDWXUHRI WKHRIIHQVHWKHFRXUWKDYLQJMXULVGLFWLRQWKHGLVSRVLWLRQRIWKHRIIHQVHDQGWKHGDWHRIGLVSR VLWLRQ Name: Title: Address: City: State: Zip Code: Telephone Number: Adjudicated Guilty: Yes No Unsatisfied Fines/Penalties: Yes No Adjudication under

Florida Deceptive and Unfair Trade Practices Act: Yes No Name: Title: Address: City: State: Zip Code: Telephone Number: Adjudicated Guilty: Yes No Unsatisfied Fines/Penalties: Yes No Adjudication under Florida ceptive and Unfair T rade Practices Act: Yes No
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'$&65HY 3DJHRI Checklist

&RSLHVRIDOOOLFHQVHVSHUPLWVDQGFHUWLILFDWLRQVREWDLQHGE\WKHDSSOLFDQWRUHPSOR\HHVRIWKHDSSOLFDQW [s. 559.904(1)(d), F.S.] 1XPEHURIHPSOR\HHVZKLFKWKHDSSOLFDQWL QWHQGVWRHPSOR\RUZKLFKDUHFXUUHQWO\HPSOR\HG [s. 559.904(1)(e), F.S.] (VWLPDWHDQG,QYRLFH)RUPV [s. 559.904(4), F.S.] Fees 7. Biennial Registration Fee Schedule; all fees are nonrefundable.

elect one. LQGLYLGXDOVZKRSHUIRUPUH SDLUVDWWKLVORFDWLRQ $100 for two year registration LQGLYLGXDOVZKRSHUIRUPUHSDLUVDWWKLVORFDWLRQ $300 for two year registration RUPRUHLQGLYLGXDOVZKRSHUIRUPUHSDLUVDWWKLVORFDWLRQ $600 for two year registration NO FEE IS REQUI RED LI\RXUUHSDLUVKRSLVORFDWHGLQ BROWARD COUNTY RU MIAMI DADE COUNTY

RU\RXUVKRSLVD OLFHQVHG MOTOR VEHICLE DEALER DQG\RXSURYLGHWKHIROORZLQJ BROWARD COUNTY VKRSVPXVWDWWDFKDFRS\RIWKHLUFXUUHQW$5RU$%OLFHQVHWRWKLVDSSOLFDWLRQ MI AMI DADE COUNTY VKRSVPXVWDWWDFKDFRS\RIWKHLUFXUUHQW095&HUWLILFDWHWRWKLVDSSOLFDWLRQ MOTOR VEHICLE DEALERS

OLFHQVHGE\WKH)ORULGD'HSDUWPHQWRI+LJKZD\6DIHW\DQG0RWRU9HKLFOHVPXVW DWWDFKDFRS\RI WKHLUFXUUHQW'+609OLFHQVHWRWKLVDSSOLF DWLRQ If you are unable to attach a current copy of your license or certificate you must use the fee schedule listed above. Prepared By (please print name): Title of Preparer: Telephone Number of Preparer: ,FHUWLI\WKDWWKLVDS

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DSSOLFDWLRQRQEHKDOIRIWKHDERYHQDP HGHQWLW\RULQGLYLGXDO Signature** Date ** Attests that person is authorized to complete form