State of Louisiana
Department of Public Safety and Corrections
Office of Motor Vehicles
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P. O. Box 64886 |
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Baton Rouge, Louisiana 70896-4886 |
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□NEW □RENEWAL |
Auto Title Company Application |
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A SEPARATE APPLICATION MUST BE SUBMITTED FOR EACH LOCATION AND EACH CO-OWNER |
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PLEASE TYPE OR PRINT |
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Business Name (must read exactly the same on both the bond and on the contract) |
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Physical Address of Business |
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Mailing Address |
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Phone No. |
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Fax No. |
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Email Address: (Mandatory) |
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Previous License No. /Authorization No. (if applicable) |
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Bond No. |
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Name of Surety Company |
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Surety’s Phone No. |
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Address |
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1.Has any license ever been denied, revoked or suspended by this Department to you or any of the principals of the partnership or corporation? Yes _____ No _____ if yes, give details below.
2.Have you ever been on probation or sentenced to jail/prison as a result of a felony conviction or guilty plea to a felony charge? Yes ____ No ____ If yes, give the law enforcement authority (city police, sheriff, FBI, etc.) the offense, date of the offense, place and disposition of case. Use back of this document if additional space is needed.
3.You are required to submit three (3) references, at least one of which must be from a current/former customer.
4.PLEASE READ THIS APPLICATION, ALL ATTACHMENTS AND THIS CERTIFICATION PRIOR TO
SIGNING THIS APPLICATION BEFORE A NOTARY PUBLIC
I HEREBY CERTIFY THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND THAT I AM FAMILIAR AND WILL ABIDE WITH THE PROVISIONS OF ALL THE LAWS, RULES AND REGULATIONS UNDER WHICH THIS REQUEST IS MADE.
OWNER’S SIGNATURE ________________________________________________________________DRIVER’S LICENSE #____________________
OWNER’S PRINTED NAME _____________________________________________________________
SWORN TO AND SUBSCRIBED BEFORE ME THIS ________________________________ DAY OF _____________________________, 20 _______
NOTARY PUBLIC SIGNATURE __________________________________________________________________________________________________
NOTARY PUBLIC PRINTED NAME & NUMBER _________________________________________________________ /____________________________
FEE: A check/money order in the amount of $200.00 must accompany request. If auto title companyhas more than one location, a separate request and a fee of $50.00 must be submitted for each additional location.
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MVCA Officer |
Dollar Amount Received |
Date Processed |
DPSMV 1968 (R 02/2012)