
Owner(s), partner(s) or corporate officers information Attach additional sheet(s) if necessary.
You must apply in person at MVED (210 N 1950 W, Salt Lake City, Utah) if:
1. you are applying for dealer license as any entity type and any of the owners are not U.S. citizens; or
2. you are a sole proprietor who is not a U.S. citizen and you are applying for any of the following licenses: body shop, crusher, distributor,
dismantler, manufacturer, factory branch, distributor branch, remanufacturer or transporter.
Bring proof that you and/or any of the owners who are not U.S. citizens are in the United States lawfully under 8 USC 1641. Also bring your/their
employment authorization card(s) and documentation showing the I-94 (arrival/departure) number(s) and Alien Registration Number(s) issued by the
U.S. Citizenship and Immigration Service.
Ð
Owner #1 name Title Home phone
Home address (physical address, not PO box) Social Security Number Driver license number and state of issue
City State ZIP Code Email address
Date of birth Hair color Eye color Height Weight Gender
Male Female
Place of birth Citizenship Race
Under state and federal law we cannot issue a license to any person who does not provide the following information.
Check one (Providing false information subjects the signer to the penalties of perjury.):
I am a U.S. citizen. SSN:
_______________________
I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully. I-94#*:
_______________________
Alien #*:
_______________________
Employment authorization card #*:
_______________________
Ð
Owner #2 name Title Home phone
Home address (physical address, not PO box) Social Security Number Driver license number and state of issue
City State ZIP Code Email address
Date of birth Hair color Eye color Height Weight Gender
Male Female
Place of birth Citizenship Race
Under state and federal law we cannot issue a license to any person who does not provide the following information.
Check one (Providing false information subjects the signer to the penalties of perjury.):
I am a U.S. citizen. SSN:
_______________________
I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully. I-94#*:
_______________________
Alien #*:
_______________________
Employment authorization card #*:
_______________________
Ð
Owner #3 name Title Home phone
Home address (physical address, not PO box) Social Security Number Driver license number and state of issue
City State ZIP Code Email address
Date of birth Hair color Eye color Height Weight Gender
Male Female
Place of birth Citizenship Race
Under state and federal law we cannot issue a license to any person who does not provide the following information.
Check one (Providing false information subjects the signer to the penalties of perjury.):
I am a U.S. citizen. SSN:
_______________________
I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully. I-94#*:
_______________________
Alien #*:
_______________________
Employment authorization card #*:
_______________________
* The Alien Registration Number (A#), I-94 (arrival/departure) number and employment authorization card are issued by the U.S. Citizenship and Immigration Service.
TC-301, page 2 of 4