MV-176 Salvage Vehicle Inspection Station Form

Georgia Department of Revenue
Motor Vehicle Division

Application for Salvage and Assembled Vehicle Inspection Location
This application for a Salvage and Assembled Vehicle Inspection Location shall be completed and accepted by the
Department of Revenue (DOR) prior to any activity related to salvage or assembled vehicle inspections.
SECTION A - STATION LOCATION INFORMATION:
______________________________________________________________________________
BUSINESS NAME (CORPORATION, LLC, SOLE PROPRIETOR OR PARTNERSHIP) BUSINESS HOURS OF OPERATION
_____________________________________________________________________________________________
STREET (NOT A P.O. BOX) CITY STATE ZIP CODE
_____________________________________________________________________________________________
BUSINESS PRIMARY PHONE NUMBER FAX NUMBER
_____________________________________________________________________________________________
POINT OF CONTACT FULL NAME PRIMARY PHONE NUMBER OR SECONDARY
_____________________________________________________________________________________________
MAILING ADDRESS, IF DIFFERENT CITY STATE ZIP CODE
SECTION B– OWNERSHIP/RELATIONSHIP INFORMATION:

CORPORATIONS & LIMITED LIABILITY COMPANIES
LEGAL NAME OF BUSINESS: _____________________________________________________
LIST PRINCIPAL OFFICERS:
NAME: _______________________________________________ TITLE: _____________________PCT: ______

RESIDENCE ADDRESS:
_____________________________________________________________________________________________
STREET (NOT A P.O. BOX) CITY STATE ZIP CODE TELEPHONE
NAME: _______________________________________________ TITLE: _____________________PCT: ______

RESIDENCE ADDRESS:
_____________________________________________________________________________________________
NAME: _______________________________________________ TITLE: _____________________PCT: ______

RESIDENCE ADDRESS:
____________________________________________________________________________________________
Registered Agent: _____________________________________
_____________________________________________________________________________________________
ADDRESS CITY STATE ZIP CODE TELEPHONE
All Shareholders and percentage of ownership, including all minority interests, is required.
You may photocopy this page and provide additional partners and interests.
Form MV-176 Page 1 of 3 April 2017

SOLE PROPRIETORSHIP or PARTNERSHIP
OWNER NAME: ______________________________________________________
RESIDENCE:
_____________________________________________________________________________________________
LIST ALL PARTNERS:
NAME: _______________________________________________ TITLE: ________________________

RESIDENCE ADDRESS:
_____________________________________________________________________________________________
NAME: _______________________________________________ TITLE: ________________________

RESIDENCE ADDRESS:
_____________________________________________________________________________________________
You may photocopy this page and provide all additional partners and interest holders.
SECTION C– STATION OPERATIONAL INFORMATION
All questions must be answered:

Will permit salvage vehicle inspections at this location a minimum of two (2) days per week? YES
Met all federal, state and local business requirements and permits? YES
Working telephone, fax and internet connection? YES
Indoor service bay? YES
Safe and secure parking for customers? YES Indoor waiting area for customers? YES
Is the location on a state road or highway that will permit the maximum load of any vehicle traveling to this
location? YES
DOR is under no obligation to provide an inspector at this location and any schedule provided by DOR for
a DOR employed salvage inspector is subject to change at any time. The station point of contact is
responsible for keeping all potential vehicle owners informed of their respective location schedule.
Employing Private Salvage Inspectors? YES NO will contract with current Private Salvage
Vehicle inspector?
o Attach or forward Salvage Vehicle Inspector Application Form MV 175 with all attachments
The Private Salvage Inspector information must be updated within 10 days and sent to DOR with
each change.
SECTION D – ATTACHMENTS TO BE INCLUDED WITH THIS APPLICATION
 Certificate of Insurance - $1,000,000.00 aggregate / $100,000 per occurrence

 Copy of State Tax Identification Registration Certificate
 DOR Salvage Vehicle Location Agreement
 Copy of Owner, all Partners and Corporate Officers Georgia Driver’s License

I understand that the Georgia Department of Revenue may periodically check the tax and Georgia
criminal history information at any time during my term without seeking additional consent from me. I do
hereby authorize a review and full disclosure of all records concerning myself to any duly authorized
agent of the Georgia Department of Revenue Special Investigations Unit, whether such records are of a
public, private, or confidential nature for criminal history and tax records.
I understand that any information obtained by a personal history background investigation, which is
developed directly or indirectly, in whole or in part, upon this release authorization, will be used in
determining my suitability for Department of Revenue registration in a position of trust. I authorize the
disclosure of the aforementioned personal information to any person(s) deemed by the Georgia
Department of Revenue to be a participant in the determination process of such suitability. I also certify
that any person(s) who may furnish such information concerning me shall not be held accountable for
giving this information; and I do hereby release said person(s) from any and all liability which may be
incurred as a result of furnishing such information. I understand that information obtained with this
authorization may be subject to public disclosure pursuant to the Georgia Open Records Act (O.C.G.A. §
50-18-70 et seq.)
I understand and acknowledge that this form will be filed with the Department of Revenue and that it is a
felony, punishable by imprisonment for not fewer than one nor more than three years or a fine of not less
than $1,000.00 nor more than $5,000.00, or both, to knowingly falsify any information on this statement.
Signature(s) of Individual, Partners (All Required), Authorized Corporate Officer
________________________________________________ DATE___________________________
Signature
_______________________________________________ ________________________________
Print Name Position
________________________________________________ DATE___________________________
Signature
________________________________________________ ________________________________
Print Name Position
WITNESS:
________________________________________________ DATE___________________________
Signature
________________________________________________ ___________________________
Printed Name Position
Submit completed application, signed with all attachments to:

[email protected]
Check or Money Order $250.00 Registration Fee will be required upon contract offer.
Date Received: ____________________________Approved Check or money order #

Denied Date ______________________________ ____________________________
Reason:

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Georgia Department of Revenue

Motor Vehicle Division

SECTION A - STATION LOCATION INFORMATION:

SECTION B– OWNERSHIP/RELATIONSHIP INFORMATION:

LIST PRINCIPAL OFFICERS:

NAME: _______________________________________________ TITLE: _____________________PCT: ______

NAME: _______________________________________________ TITLE: _____________________PCT: ______

NAME: _______________________________________________ TITLE: _____________________PCT: ______

Registered Agent: _____________________________________

Form MV-176 Page 1 of 3 April 2017

OWNER NAME: ______________________________________________________

LIST ALL PARTNERS:

NAME: _______________________________________________ TITLE: ________________________

NAME: _______________________________________________ TITLE: ________________________

SECTION C– STATION OPERATIONAL INFORMATION

All questions must be answered:

SECTION D – ATTACHMENTS TO BE INCLUDED WITH THIS APPLICATION

 Certificate of Insurance - $1,000,000.00 aggregate / $100,000 per occurrence

Form MV-176 Page 2 of 3 April 2017

Signature(s) of Individual, Partners (All Required), Authorized Corporate Officer

Submit completed application, signed with all attachments to:

Date Received: ____________________________Approved Check or money order #

Form MV-176 Page 3 of 3 April 2017

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