HomeMy WebLinkAboutPWR ApplicationCounty of Hawaii
Department of Finance
Vehicle Registration and Licensing Division
101 Pauahi Street, Suite #5
Hilo, Hawai'i, 96720 -4224
(808) 961 -8351 • (808)961 -8330 (Fax)
New License, or
Renewal
For Office use only: Sequence No.
New No. Previous No.
Application for License(s) to Deal in Used Motor Vehicle Parts or Used Motor Vehicle
Accessories; To Engage in the Business of Wrecking, Salvaging, or Dismantling Motor
Vehicles; To Rebuild Motor Vehicles
FOR THE YEAR ENDING JUNE 30,
To the Director of Finance, County of Hawai'i, State of Hawai'i:
In accordance with Chapter 289, Hawai'i Revised Statutes, and the Rules and Regulations of the
Director of Finance, County of Hawai'i, the undersigned hereby applies for a license to engage in the
business of (mark applicable box or boxes):
I❑ Purchasing or selling used motor vehicle parts or accessories License Fee: $10.00
F1Wrecking, salvaging, or dismantling motor vehicles for the License Fee: $10.00
purpose of reselling the parts or accessories
❑ Rebuilding wrecked or dismantled vehicles for the purpose of License Fee: $10.00
resale.
NOTE: The fee for EACH of the above is $10.00.
1. Name of Applicant:
2. Business Name:
3. Principal place of business
4. Mailing address:
Phone:
5. Address of each place of business other than principal place above:
County of Hawaii is an Equal Opportunity Provider and Employer. Complaints of discrimination should be sent to
USDA, Director, Office of Civil Rights, Washington, DC 20250-9410 Or call (202) 720 -5964 (Voice and TDD).
Last Updated 07/30112
6. List name, residence address, and date and place of birth of applicant. If partnership or joint
venture, list name, residence address, and date and place of birth of each partner or joint
venturer. If corporation, list name, residence address, and date and place of birth of each of its
officers and directors.
Name
Residence Address Date /Place of Birth
7. List names and addresses of all employees involved in the business for which license(s) is (are)
applied. (Attach additional sheet if more space is required.)
E-*
Have you ever applied for a license under Chapter 289, HRS?
If yes, give date of last application:
If yes, give date of last license issued:
County
County
Was any license issued to you under Chapter 289 ever revoked
orsuspended?
If yes, give particulars in Item 15.
10. Has any person named in Items 5 or 6 (partners, joint venturers,
officers and directors, or employees) been the holder of a
license issued under Chapter 289 which was revoked or
suspended?
If yes, give name(s) of person(s):
11. Has any person named in Items 5 or 6 been refused a license
under Chapter 286?
If yes, give particulars in Item 15.
V,
OYES KDNO
ILI 67� � �
12. Has any person named in Items 6 or 7 been convicted of a felony
or misdemeanor involving moral turpitude, and not pardoned? YES NO
If yes, give particulars in Item 15.
13. Has applicant or any person named in Items 6 or 7 been found
to have committed any fraudulent act in connection with the
business of dealing in used motor vehicle parts or accessories
and /or in the business of wrecking, salvaging, and rebuilding
motor vehicles? YES ONO
If yes, give particulars in Item 15.
14. If this is an application for renewal of license, are there any
proceedings pending for the revocation or suspension of your
existing license? YES r9NO
15
If yes, give particulars in Item 15.
Use this space to explain answer to questions asked above. Attach additional sheet if more space is required.
Each person named in Items 6 and 7 must request the Police Department to furnish
the Director of Finance, Treasury Division, with an Abstract of Criminal Record.
I(We)
do solemnly swear that the statements contained in the foregoing application are
true and correct and that I, as an individual or as an officer of the corporation, or we,
as members of the partnership or joint venture, have authority to sign this application
and to make the statements contained herein on behalf of the applicant.
Subscribed and sworn to before me this
day of
Notary Public, State of Hawaii
My commissions expires
, 20
3