Form Dmv 126 M Ds – Fill Out and Use This PDF

DMV-126-M-DS REV 03/11

THE BUSINESS NAME AND ADDRESS INFORMATION BELOW SHOULD MATCH WHAT IS ON YOUR CURRENT DEALER LICENSE CERTIFICATE

Dealership Name:

Telephone Number (

)

Mailing Address:

STREET ADDRESS

CITY

STATE

ZIP

Business Address:

STREET ADDRESS

CITY

STATE

ZIP

Dealer License Number:

Change in Dealership • This section outlines the change in dealership that must be completed.

1.If business is moved to a new location, give complete new mailing address and new location of business. Attach to this notice a photograph of new location. A $5.00 per plate charge applies if mailing address is changing.

New Address:

STREET ADDRESS

CITY

STATE

ZIP

2.If change in trade name is made, give the complete new trade name that the business will be operated under. A $5.00 per plate charge applies to name changes.

Dealership Name:

3.If change is due to death of licensee or any partner, give name of such licensee or partner and relationship to licensee.

Deceased’s Name:		Relationship:
Deceased’s Name:		Relationship:

4.If change in any partners, oers or members, list names and titles below:

Name:		Title:
Name:		Title:
Name:		Title:

5.If appointment of a trustee in bankruptcy, trustee assignment for beneeditor, master or receiver, give name and address of such trustee, master or receiver.

CONTINUED IN REVERSE SIDE

Continued Detailed Dealer Questionnaire

6.If change in personnel authorized to make assignment of titles and to transact business with the DMV, list names of all authorized personnel.

Name:		Signature: (X)
Name:		Signature: (X)
Name:		Signature: (X)
Name:		Signature: (X)
Name:		Signature: (X)

7.If additional places of business have been established at other locations with the State since your original application was , give the address and phone number of each location. Attach a photograph of each location to this

notice. Include a check or money order for $1.00 per each location.

Address:					Telephone Number (	)
	STREET ADDRESS	CITY	STATE	ZIP
Address:					Telephone Number (	)
	STREET ADDRESS	CITY	STATE	ZIP
Dealer and Notary Public Certi
State of West Virginia, County of					to wit:
Before the undersigned authority this day personally appeared						,
who, after
member of the

address and location shown herein and applicant further states that the changes outlined in this notice are true and correct statements.

(X)

SIGNATURE

(X)

SIGNATURE

(X)

SIGNATURE

(X)

SIGNATURE

Subscribed and sworn before me this _________ day of _________________________, 20_____.

_________________________________________________________________________

NOTARY PUBLIC SIGNATURE

My Commission expires on ___________/____________/____________________.