Get TX CCS-FRM-257 - Dallas 2011

APPLICATION FOR CITY OF DALLAS REPAIR LICENSE Department of Code Compliance Consumer Protection Division MOTOR VEHICLE REPAIR - 200. Address Zip A separate application must be filed for each separate establishment within the City of Dallas. To your knowledge has any current employee of this business been convicted of a violation of any provision of the ordinance pertaining to the type of repair license applied for YES If YES provide details license being applied for CERTIFICATE OF OCCUPANCY OR HAVE APPLIED FOR A CERTIFICATE OF OCCUPANCY INSPECTION REQUEST AND MUST PROVIDE A COPY OF YOUR VALID CERTIFICATE OF OCCUPANCY OR CERTIFICATE OF OCCUPANCY INSPECTION REQUEST if applicable WITH LICENSE APPLICATION. PLEASE PROVIDE A LEGIBLE COPY OF THE PERSON IN CONTROL DRIVER S LICENSE OR APPROVED IDENTIFICATION CARD. As owner proprietor partner corporate officer or authorized agent of the above firm I certify that the firm will/does engage in Motor Vehicle/ Mobile Motor Vehicle/Home/ Electronic Repair within the City of Dallas as defined in Chapter 50 of the Dallas City Code. As owner proprietor partner corporate officer or authorized agent of the above firm I certify that the firm will/does engage in Motor Vehicle/ Mobile Motor Vehicle/Home/ Electronic Repair within the City of Dallas as defined in Chapter 50 of the Dallas City Code. I further certify that all facts stated in the application are true and correct to the best of my knowledge and belief. Signature Date Date of Birth THE DIRECTOR OF THE DEPARTMENT OF CODE COMPLIANCE MUST BE NOTIFIED OF ANY CHANGE OF ADDRESS OWNERSHIP OR MANAGEMENT WITHIN 10 DAYS OF SUCH CHANGE. NOTICE An applicant who purchases a City of Dallas Repair License and whose check or draft is returned by their financial institution for any reason will be considered to be engaged in the repair business without a valid license. In the event your check is returned for insufficient or uncollected funds we may represent your check electronically. To your knowledge has any current employee of this business been convicted of a violation of any provision of the ordinance pertaining to the type of repair license applied for YES If YES provide details license being applied for CERTIFICATE OF OCCUPANCY OR HAVE APPLIED FOR A CERTIFICATE OF OCCUPANCY INSPECTION REQUEST AND MUST PROVIDE A COPY OF YOUR VALID CERTIFICATE OF OCCUPANCY OR CERTIFICATE OF OCCUPANCY INSPECTION REQUEST if applicable WITH LICENSE APPLICATION. PLEASE PROVIDE A LEGIBLE COPY OF THE PERSON IN CONTROL DRIVER S LICENSE OR APPROVED IDENTIFICATION CARD. As owner proprietor partner corporate officer or authorized agent of the above firm I certify that the firm will/does engage in Motor Vehicle/ Mobile Motor Vehicle/Home/ Electronic Repair within the City of Dallas as defined in Chapter 50 of the Dallas City Code. I further certify that all facts stated in the application are true and correct to the best of my knowledge and belief. Signature Date Date of Birth THE DIRECTOR OF THE DEPARTMENT OF CODE COMPLIANCE MUST BE NOTIFIED OF ANY CHANGE OF ADDRESS OWNERSHIP OR MANAGEMENT WITHIN 10 DAYS OF SUCH CHANGE. NOTICE An applicant who purchases a City of Dallas Repair License and whose check or draft is returned by their financial institution for any reason will be considered to be engaged in the repair business without a valid license. 00 Additional Electronic Repair License - 175. 00 FOR OFFICE USE ONLY DATE PAID ACCOUNT NUMBER / EXPIRATION DATE FEE PAID INSTRUMENT NUMBER INTRUMENT TYPE CK MO CC CASH PAYOR If different than custom/applicant capture address C/S/Z phone number ADDRESS CITY STATE ZIP - ALL FEES ARE NON-REFUNDABLE MAKE CHECK OR MONEY ORDER PAYABLE TO City of Dallas TO PAY IN PERSON City of Dallas Special Collections 1500 Marilla St. Room 2DS Dallas TX 75201 PHONE LICENSE IS NOT TRANSFERABLE OR MAIL PAYMENT TO PO Box 139076 Dallas TX 75313-9076 Business Name Business Address Physical Location Street Suite City/State Zip Code Mailing Address if different Business Phone Fax Home Phone Email Type of ownership Individual Partnership Cell Phone Corporation Other If incorporated name registered with Secretary of State Federal ID NAME AND ADDRESS OF REGISTERED AGENT OR INDIVIDUAL AUTHORIZED TO BE SERVED FOR ADMINISTRATIVE AND LEGAL PROCESS RELATIVE TO THE CITY OF DALLAS REPAIR ORDINANCES. Name CCS-FRM-257 Effective Date 10/03/2011 Number Rev 4 If not incorporated ownership information Home Address Telephone D. O. B. TX. DL Do you operate a Tire establishment other than listed above YES NO If YES provide information below. Address Zip A separate application must be filed for each separate establishment within the City of Dallas. I further certify that all facts stated in the application are true and correct to the best of my knowledge and belief. Signature Date Date of Birth THE DIRECTOR OF THE DEPARTMENT OF CODE COMPLIANCE MUST BE NOTIFIED OF ANY CHANGE OF ADDRESS OWNERSHIP OR MANAGEMENT WITHIN 10 DAYS OF SUCH CHANGE. NOTICE An applicant who purchases a City of Dallas Repair License and whose check or draft is returned by their financial institution for any reason will be considered to be engaged in the repair business without a valid license. In the event your check is returned for insufficient or uncollected funds we may represent your check electronically. For Code Compliance Use Only Establishment has been inspected and meets minimum Health and Sanitation Standards for operation. Chapter 19-34. O. B. TX. DL Do you operate a Tire establishment other than listed above YES NO If YES provide information below. Address Zip A separate application must be filed for each separate establishment within the City of Dallas. To your knowledge has any current employee of this business been convicted of a violation of any provision of the ordinance pertaining to the type of repair license applied for YES If YES provide details license being applied for CERTIFICATE OF OCCUPANCY OR HAVE APPLIED FOR A CERTIFICATE OF OCCUPANCY INSPECTION REQUEST AND MUST PROVIDE A COPY OF YOUR VALID CERTIFICATE OF OCCUPANCY OR CERTIFICATE OF OCCUPANCY INSPECTION REQUEST if applicable WITH LICENSE APPLICATION. PLEASE PROVIDE A LEGIBLE COPY OF THE PERSON IN CONTROL DRIVER S LICENSE OR APPROVED IDENTIFICATION CARD. 00 Additional Location for MVP License - 200. 00 Replacement License - 2. 00 HOME REPAIR - 100. 00 ELECTRONIC REPAIR - 175. 00 Additional Electronic Repair License - 175. 00 FOR OFFICE USE ONLY DATE PAID ACCOUNT NUMBER / EXPIRATION DATE FEE PAID INSTRUMENT NUMBER INTRUMENT TYPE CK MO CC CASH PAYOR If different than custom/applicant capture address C/S/Z phone number ADDRESS CITY STATE ZIP - ALL FEES ARE NON-REFUNDABLE MAKE CHECK OR MONEY ORDER PAYABLE TO City of Dallas TO PAY IN PERSON City of Dallas Special Collections 1500 Marilla St. Room 2DS Dallas TX 75201 PHONE LICENSE IS NOT TRANSFERABLE OR MAIL PAYMENT TO PO Box 139076 Dallas TX 75313-9076 Business Name Business Address Physical Location Street Suite City/State Zip Code Mailing Address if different Business Phone Fax Home Phone Email Type of ownership Individual Partnership Cell Phone Corporation Other If incorporated name registered with Secretary of State Federal ID NAME AND ADDRESS OF REGISTERED AGENT OR INDIVIDUAL AUTHORIZED TO BE SERVED FOR ADMINISTRATIVE AND LEGAL PROCESS RELATIVE TO THE CITY OF DALLAS REPAIR ORDINANCES. Name CCS-FRM-257 Effective Date 10/03/2011 Number Rev 4 If not incorporated ownership information Home Address Telephone D. O. B. TX. DL Do you operate a Tire establishment other than listed above YES NO If YES provide information below. .