Tdlr Form Apr001 – Fill Out and Use This PDF

TEXAS DEPARTMENT OF LICENSING AND REGULATION

P.O. Box 12157 - Austin, Texas 78711-2157

1-800-803-9202, 512-463-6599, FAX 512-463-5984 www.license.state.tx.us - automotive.parts.recyclers@license.state.tx.us

USED AUTOMOTIVE PARTS RECYCLING BUSINESS APPLICATION

PURSUANT TO TEXAS OCCUPATIONS CODE, CHAPTER 2309

RECEIPT NUMBER

PMT. AMOUNT

MONEY TYPE

$120

DO NOT WRITE ABOVE THIS LINE

1.Name of Company:

2.DBA:

3.Physical Location: STREET ADDRESS MUST BE DESIGNATED BELOW. (A license will not be issued to a P.O. Box.)

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

Number, Street, Suite, Apt

_________________________________________________________________________________________________________________________________________

City

State

Zip

4.Mailing Address: (USED FOR ALL CORRESPONDENCE) (P.O. Box is allowed for this address.)

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

Number, Street, Suite, Apt

_________________________________________________________________________________________________________________________________________
City	State	Zip

5.	Phone: (	)	-	6. Fax: (	)	-
7.	Contact:
	_________________________________________________			____________________________________________________
	Name			Title
	(_________)________-_______________________________			____________________________________________________
	Phone			Email
8.	Type of Ownership:
	Corporation		Partnership	Sole Proprietor		Limited Liability Co (LLC)
	Limited Liability Partnership (LLP) Other ____________________________________________

9. Federal ID #: _________________________		OR *Social Security #: ________________________
(For information on the Federal ID # go to www.irs.gov/business.)			(If Sole Proprietor provide SS # instead of Fed ID #)
10. Agent for Service: (required if out of state business)
________________________________________________		(		)	-________	_________________________
Name			Phone
						TX	______________
Street Address					City		Zip

TDLR Form APR001 (07/2010) Attachment A Required

This document is available on the TDLR website at www.license.state.tx.us/ parts/ aprforms.htm

11. Insurance: Call your insurance agent to obtain a Certificate of Insurance

Is certificate of insurance attached? _____ YES _____NO

Attach a certificate of insurance documenting that this company has general liability insurance of not less than $250,000 as required by the Texas Used Automotive Parts Recycling Act § 2309.153 (2) and the Used Automotive Parts Recycling Administrative Rules § 87.40.

Requirements for the Certificate of Insurance:

 Use a standard ACORD Certificate of Insurance form;

 List the type of insurance, policy #, effective and expiration dates, and limits (Combined Single Limits $250,000);

 Name and physical address of insured must match the company name and physical address on this applica- tion or be specified in the description of operations/locations area;

 Indicate that the policy is for general liability OR garage liability;

 Certificate holder must be: TDLR, PO Box 12157, Austin, TX 78701;

 Insurance company will provide a 30 day written notice of cancellation or non-renewal to TDLR.  To see an example of a Certificate of Insurance go to www.license.state.tx.us/parts/aprforms.htm.

12.Storm Water Permit: The Texas Used Automotive Parts Recycling Act requires an applicant to provide proof of a storm wa- ter permit, if the applicant is required by the Texas Commission on Environmental Quality (TCEQ) to obtain a permit.

Are you required to obtain a storm water permit? _____Yes _____No If yes, attach a copy of your storm water permit.

If no, please note that by checking no, you attest that you are aware of the requirements for a storm water permit and have determined that you are not required by TCEQ to obtain a storm water permit.

If you’ve applied for but not yet received your storm water permit, under what Company Name did you apply?

Company Name: _______________________________________________________________________________________________

13. *Social Security number disclosure:

Section 231.302 of the Texas Family Code REQUIRES all applicants to disclose their Social Security Number (SSN) when filing an application. The SSN that is provided is confidential and is required to enforce Child Support orders. Failure to pro- vide the SSN will prevent a license from being issued and could ultimately lead to termination of the application. For more information regarding child support payments, contact the Texas Attorney General at: www.oag.state.tx.us/child/index or call (512)460-6000 or (800)252-8014.

14.Notice Regarding Applicable Fees: If you submit an insufficient fee amount with this application, or

submit an outdated application form, the form and fee may be returned to you. To verify the correct form version consult the TDLR web site (www.license.state.tx.us/parts/aprforms.htm) or contact TDLR using the information at the top of the first page.

A $120 fee is required with this application. Application fees are not refundable. Make check or money payable to the Texas Department of Licensing and Regulation.

15.By signing and submitting this application, I certify that information submitted on this and any attached forms is true and correct. I further certify that I will comply with all applicable pro- visions of the Texas Used Automotive Parts Recycling Act; Texas Occupations Code, Chapter 2309; TEX. ADMIN. CODE, Chapter 60; the Used Automotive Parts Recycling Administrative Rules, TEX. ADMIN. CODE, Chapter 87; I understand that providing false information on this ap- plication may result in revocation and/or denial of the license I am requesting and the imposition of administrative penalties and sanctions.

_______________________________________________________________________________________________

Signature of Owner, Partner, Officer or Authorized AgentPrinted Name

_______________________________________________________________________________________________

Title

Date

TDLR Form APR001 (07/2010) Attachment A Required

This document is available on the TDLR website at www.license.state.tx.us/ parts/ aprforms.htm

USED AUTOMOTIVE PARTS RECYCLING BUSINESS APPLICATION: ATTACHMENT A,

PURSUANT TO TEXAS OCCUPATIONS CODE, CHAPTER 2309

Name of Used Automotive Parts Recycling Company:

Background information on Applicants, Owners, Partners, Principals, Corporate Of- ficers, and General Manager(s) Use additional sheets, if necessary.

Used Automotive Parts Recycling Business License Eligibility as required by § 87.21.

An applicant, a partner, principal, officer, or general manager of the applicant, or another license or permit holder with a con- nection to the applicant may be ineligible for a used automotive parts recycling business license, if the applicant, a partner, principal, officer, or general manager of the applicant, or another license or permit holder with a connection to the applicant has:

(1)before the application date, been convicted of, pleaded guilty or nolo contendere to, or been placed on de- ferred adjudication for:

(A)a felony; or

(B)a misdemeanor punishable by confinement in jail or by a fine exceeding $500;

(2)violated an order of the commission or executive director, including an order for sanctions or administrative penalties; or

(3)knowingly submitted false information on the application.

Name:______________________________________________________________________________

Last,First,Initial

Title: ______________________________________________________________________________

_______/________/__________	____ MALE ____ FEMALE	____ ____ ____ - ____ ____ - ____ ____ ____ ____
Date of Birth (MM/DD/YYYY)	Gender (check one)	*Social Security Number

Have you been convicted of a criminal offense or been placed on deferred adjudication? ___YES ____NO

If YES, then attach a “Criminal History Questionnaire.” A Criminal History Questionnaire may be found at www.license.state.tx.us/parts/aprforms.htm.

Have you ever had an occupational license, certification or registration suspended, revoked or denied in any state? ____ YES ____NO If YES, then attach a “Disciplinary Action Questionnaire” A Disciplinary Ac-

tion Questionnaire may be found at www.license.state.tx.us/parts/aprforms.htm.

Name:______________________________________________________________________________

Last,First,Initial

Title: ______________________________________________________________________________

_______/________/__________	____ MALE ____ FEMALE	____ ____ ____ - ____ ____ - ____ ____ ____ ____
Date of Birth (MM/DD/YYYY)	Gender (check one)	*Social Security Number

Have you been convicted of a criminal offense or been placed on deferred adjudication? ___YES ____NO

If YES, then attach a “Criminal History Questionnaire.” A Criminal History Questionnaire may be found at www.license.state.tx.us/parts/aprforms.htm.

Have you ever had an occupational license, certification or registration suspended, revoked or denied in any state? ____ YES ____NO If YES, then attach a “Disciplinary Action Questionnaire” A Disciplinary

Action Questionnaire may be found at www.license.state.tx.us/parts/aprforms.htm.

Use additional sheets if necessary.

TDLR Form APR001 (07/2010)

This document is available on the TDLR website at www.license.state.tx.us/ parts/ aprforms.htm