
ALABAMA DEPARTMENT OF REVENUE
MOTOR VEHICLE DIVISION
P.O. Box 327640 • Montgomery, AL 36132-7640
Dealer Application For Designated Agent
All new and used dealers are required by law to become designated agents of the department.
The dealer regulatory license bond satisfies the designated agent bonding requirement.
MVT 4-1
Rev. 5/18
COMPANY NAME: TELEPHONE:
PHYSICAL ADDRESS (notify this department immediately of address changes):
MAILING ADDRESS (if different from above):
CITY: COUNTY: STATE: ZIP:
STATE SALES TAX ACCOUNT NO.: ACT #539 REGULATORY LICENSE NO.: COUNTY OCCUPATIONAL LICENSE NO.: MANUFACTURED HOME LICENSE NO.:
1) Individual SSN: ______________________________________________________
2) Partnership FEIN: ______________________________________________________
3) Corporation FEIN: ______________________________________________________
PRINCIPAL NAME(S) TITLE HOME ADDRESS HOME TELEPHONE
1
2
3
Has the applicant ever been convicted of violating any felony provisions of Chapter 8 or 20 of Title 32, or Title 40 of the Code of Alabama
1975?
Yes
No. If the answer is yes, please explain and provide specific details on a separate page.
Has any of the principals previously been a designated agent or principal thereof?
Yes
No. If yes, list designated agent name and number: ___________________________________________________________
The undersigned states under the penalties of perjury that all information contained in this application is true and correct to the best of his/her
knowledge and belief.
__________________________________________________________________
NAME OF FIRM
BY:__________________________________________________________________
SIGNATURE AND TITLE
IF THE BUSINESS IS A PARTNERSHIP, ALL PARTNERS MUST SIGN THIS APPLICATION AS WELL AS THE BOND.
DEPARTMENT USE ONLY
Approved this _________ day of ________________________, 20_____. ____________________________________________________
COMMISSIONER OF REVENUE
Designated Agent Number _____________________________________