State Form 13215 – Fill Out and Use This PDF

1. Name in which the business license will be issued

2. Federal identification number (FIN)

3. Daytime telephone number

Evening telephone number

Fax number

E-mail address

(

)

(

)

(

)

4. Legal address of business (number and street)

City

State

ZIP code

County

5. Tax identification number

Location number

6. The business location is:

If leased, name of lessor

Leased

Owned

Address of lessor (number and street)

City

State

ZIP code

Telephone number of lessor

(

)

7a. Name of insurance carrier

Policy number

Date of expiration (month, day, year)

7b. Name of bond carrier

Bond number

Effective date of bond (month, day, year)

8a. Type of dealer (check one)

Vehicle

Watercraft

8b. Indicate the type of license being applied for by checking the appropriate box.

Dealer

Factory Representative

Distributor

Converter Manufacturer

Wholesale Dealer

Manufacturer

Distributor Representative

Automobile Auction

Research and Development

Transfer Dealer

9. If applying for a LICENSE, indicate the type of vehicles sold by checking the appropriate box(es).

CARS

TRUCKS

MOTORCYCLES MOBILE HOMES

TRAILERS

RECREATIONAL

ALL TERRAIN

BOATS

OTHER

New Only

New Only

New Only

New Only

New Only

VEHICLES

VEHICLES (ATVs)

New Only

New Only

Used Only

Used Only

Used Only

Used Only

Used Only

New Only

New Only

Used Only

Used Only

New & Used

New & Used

New & Used

New & Used

Used Only

Used Only

New & Used

New & Used

New & Used

New & Used

New & Used

If you checked Other, please explain.

10. Number of full-time sales persons directly

11. Number of other full-time employees

12. How many units do you expect to sell during the next twelve (12) months?

involved with selling

Wholesale ____________

Retail ____________

13. Type of applicant (check one)

a. Sole proprietorship

b. Partnership

c. Corporation

d. LLC

e. LLP

14. Do you intend to buy dealer plates?

15. Do you intend to buy interim plates?

Yes

No

How many? ____________

Yes

No

How many? ____________

Original ink signature

Date (month, day, year)

Printed or typed name

Title

Authorizing agency

A. Name of primary owner

Title

Home address (number and street)

ZIP code

City

State

Home telephone number

(

)

B. Name of additional owner

Title

Home address (number and street)

ZIP code

City

State

Home telephone number

(

)

C. Name of additional owner

Title

Home address (number and street)

ZIP code

City

State

Home telephone number

(

)

18. Has any owner, partner, officer, or director of the applicant owned or worked for another dealership in this or any other state?

Yes

No

If yes, name of individual

Name of dealership

Address of dealership (number and street)

City

State

ZIP code

If yes, name of individual

Name of dealership

Address of dealership (number and street)

City

State

ZIP code

19. Name of person upon whom legal service or process may be made

Address (number and street, city, state, and ZIP code)

Telephone number

(

)

20. If corporation, LLC, or LLP, state of action

Date of action (month, day, year)

If foreign corporation (not Indiana), date of admission to do business in Indiana

(month, day, year)

21. REPRESENTATIVE

ADDRESS (NUMBER AND STREET)

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

22. QUESTIONS

Has any owner, partner, or director on the application ever been arrested or convicted of a crime that has not been

Yes

No

expunged by a court?

If yes, please give details.

Has any owner, partner, or director on the application had a license suspended, or revoked or had an application

Yes

No

for a license denied in this or any other state?

If yes, please explain.

Is this location devoted solely to the business of buying, selling, and/or exchanging motor vehicles?

Yes

No

If no, please explain.