SALESPERSON/REPRESENTATIVE LICENSE APPLICATION For DMV Office Use Only Wisconsin Department of Transportation Exam Date MV2184 10/2018 Ch. 218 Wis. Stats. See instructions and fee schedule on reverse. Complete all sections of the application. Fees Collected Incomplete applications will not be processed; they will be returned to the employer. $ License Type Check One Employer’s Dealer License Number PMR Number – Motor Vehicle Salesperson License Expiration Date Service Center Recreational Vehicle Salesperson Manufacturer/Distributor Representative Fee Enclosed Badge Number $ Your Full Name Last First MI Home Address Street Number and Name or Rural Route Number – City Zip Code Email Address Gender Birth Date Height Weight Eye Color Hair Color Female Male Driver License Number or ID Number If none, indicate State of License or ID Social Security Number For Verification Purposes – “None” – Yes No Have you been licensed as a salesperson in Wisconsin within the last 5 years? If yes, what year? Dealer Name Dealer Number City Was similar license ever denied, suspended or revoked in this or any state? If yes, explain. Have you ever been convicted or a List all conviction(s) and date(s) or conviction(s). Are any criminal charges pending against you? List all charge(s) and date(s) or arrest. List any other names by which you are known. Last First MI Applicant Statement I, the undersigned, affirm under penalty of s.946.32 or s.345.17 Wisconsin Statutes, that the answers and statements on this application are true and correct. I understand that a misstatement on this application or any supporting documents might result in the denial, suspension or revocation of my salesperson or representative license under Ch. 218 Wisconsin Statutes. I authorize the department or its agent to verify this information. X (Applicant) (Date) To Be Completed By Employer If this salesperson will work at more than one location, see special instructions for multiple dealerships on reverse. I certify that I have reviewed the above information and request that the Dealer/Manufacturer Name license be issued. I agree to give the applicant appropriate training BEFORE permitting him/her to transact business. I understand that I am Dealer Number responsible for the sales or representative practices of this employee and that his/her actions may be grounds for the denial, suspension or Street Address revocation of my business license. X City, State, Zip Code (Company Officer or Duly Authorized (Date) (Area Code) Telephone Number (Title)
SALESPERSON/REPRESENTATIVE LICENSE APPLICATION Wisconsin Department of Transportation MV2184 10/2018 Ch. 218 Wis. Stats. See instructions and fee schedule on reverse. Complete all sections of the application. Incomplete applications will not be processed; they will be returned to the employer. For DMV Office Use Only Exam Date Fees Collected $ License Type – Check One Motor Vehicle Salesperson Recreational Vehicle Salesperson Manufacturer/Distributor Representative Employer’s Dealer License Number PMR Number License Expiration Date Service Center Fee Enclosed $ Badge Number Your Full Name Last First MI Home Address – Street Number and Name or Rural Route Number City Zip Code Email Address Gender Female Male Birth Date Height Weight Eye Color Hair Color Driver License Number or ID Number – If none, indicate “None” State of License or ID Social Security Number – For Verification Purposes Yes No Have you been licensed as a salesperson in Wisconsin within the last 5 years? If yes, what year? Dealer Name Dealer Number City Was similar license ever denied, suspended or revoked in this or any state? If yes, explain. Have you ever been convicted or a List all conviction(s) and date(s) or conviction(s). Are any criminal charges pending against you? List all charge(s) and date(s) or arrest. List any other names by which you are known. Last First MI Applicant Statement I, the undersigned, affirm under penalty of s.946.32 or s.345.17 Wisconsin Statutes, that the answers and statements on this application are true and correct. I understand that a misstatement on this application or any supporting documents might result in the denial, suspension or revocation of my salesperson or representative license under Ch. 218 Wisconsin Statutes. I authorize the department or its agent to verify this information. X (Applicant) (Date) To Be Completed By Employer If this salesperson will work at more than one location, see special instructions for multiple dealerships on reverse. Dealer/Manufacturer Name I certify that I have reviewed the above information and request that the license be issued. I agree to give the applicant appropriate training BEFORE permitting him/her to transact business. I understand that I am responsible for the sales or representative practices of this employee and that his/her actions may be grounds for the denial, suspension or revocation of my business license. X Dealer Number Street Address City, State, Zip Code (Company Officer or Duly Authorized (Date) (Area Code) Telephone Number (Title)
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