Virginia Btro 1 Form – Fill Out and Use This PDF

BUSINESS INFORMATION

6.Did you own and operate your towing and recovery business on or before January 1, 2006?

No

Yes If yes, please include supporting documentation, including, but not limited to, a copy of a state or federal tax return, or a local business license; a receipt for payment of other taxes or governmental fees; or paid purchase order forms or similar documents related to the repair, lease, or purchase of a tow truck.

7.List the street addresses for ALL other facilities and offices (attach a separate page if necessary).

(a)

(b)

(c)

9.Provide the full name of the Responsible Individual, their title, SSN or DMV Customer Number, and a number where they can be easily reached. The Responsible Individual is the person representing the business and is accountable for all aspects of the license for the operator. The Responsible Individual must be knowledgeable of all applicable state, federal, and local laws and regulations related to the tow and recovery services the licensee offers or renders, and for ensuring that the operator conforms to them. The Responsible Individual is either the principal owner or chief executive officer of the business entity, or manager of business operations for the operator. Additionally, they should be readily available and able to timely respond to the Board.

Responsible Individuals Full Name:

10.List the name of the Principal Owner (if more than one Principal Owner, list all) and all other individuals involved in the management and operation of the business. For example, the sole proprietor, partners of a general partnership, managing partner of a limited partnership, officers/directors of an association, managers/members of a limited liability company, or officers of a corporation (attach a separate list if necessary).

BUSINESS INFORMATION

Yes No

14Has any local, Virginia or other state, or national regulatory body subjected the applicant, the Responsible Individual, or the Principal Owner to suspension or revocation of any license or certification?

If yes, provide copies of the findings, and identify the entity.

15.Has the owner, manager, or other individual involved in the operation, management, or conduct of the business, including the Responsible Individual, ever been convicted of any misdemeanor criminal offense?

If yes, provide a certified copy of the applicable warrants.

16.Has the owner, manager, or other individual involved in the operation, management, or conduct of the business, including the Responsible Individual, ever been convicted of any felony criminal offense? If yes, identify the individual(s) below, provide a certified copy of the applicable warrants, a national criminal history record check for each person, and any other information that you would like the Board to consider including status of incarceration, parole or probation, reference letters, etc.. If the person is applying for a Driver's Authorization Document, a national criminal history record check is not required.

Payment Options

1.Check or money order made payable to the "Treasurer of Virginia" in the amount of $_____________

2.Credit Card - This section is to be used for CREDIT CARD PAYMENTS ONLY. If you elect this form of payment, complete this section in its entirety. Failure to complete this section in its entirety will result in the return of the application. If the fee is not calculated properly, the cardholder authorizes the Board to adjust the total fee due (including overages and shortages).

Credit Card Type

MasterCard, Visa, American Express or Discover

Credit Card No.

Month and Year

Card Verification Code

(Last three numbers on the back of a Master Card/Visa/Discovery or four numbers found on front of American Express)

Cardholder Name (Print)

Cardholder Address:

(As shown on credit card statement including street or PO Box number)

(As shown on credit card statement including city, state, and zip code)

Cardholder Signature: