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(Please PRINT or TYPE)
Date:
____________________________
Dealer Registration
Number:
___________________________________________________
Legal Name:
_______________________________________________________________
Trade Name:
_______________________________________________________________
Business Address:
__________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Business Telephone
Number:
_________________________________________________
The following persons
(must be an owner or
employee) are authorized to
present
dealer transfers on
behalf of the above dealer
until further notice:
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Name
(include
full first and last
name)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
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Position (e.g. runner,
salesperson, owner)
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
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Authorized by: (üone)
¨ Sole Proprietor
¨
Partner
¨ Signing Officer of
Corporation
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___________________________________
Print Name
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__________________________________
Signature
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© 2012 OMVIC This information is provided as a public service by 
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