Get Ca Bar-101 (formerly Lic Std 08) 2021-2024

D. Number First LIC STD 08 Rev 05/11 Area Code and Telephone Number Driver License Number Title Page 1 of 5 8. BUSINESS CONSUMER SERVICES AND HOUSING AGENCY GOVERNOR EDMUND G* BROWN JR* Bureau of Automotive Repair Licensing Unit P. O. Box 989001 West Sacramento CA 95798-9001 P 855 735-0462 F 855 641-9982 www. smogcheck. ca*gov For Department Use Only APPLICATION FOR AUTOMOTIVE REPAIR DEALER REGISTRATION Application for Sole Proprietorship Partnership Not LP Corporation Not LLC Fee 200. 00 Registration Number Issue Date Business Type INSTRUCTIONS Receipt Number 1. Read attached instructions and all information contained in this application* 2. Remit fees by check or money order made payable to the Licensing Unit. ATS Number 3. Submit completed application with all requirements and fees to the Licensing Unit at the above address. 4. All information is mandatory and is required under Business and Professions Code Section 9884 and California Code of Regulations 3351. Please write N/A or Exempt if an item does not apply to your business structure. PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 158 FEES ARE NON-REFUNDABLE* Please type or print legibly in ink BLANK SPACES WILL DELAY THE PROCESSING OF YOUR APPLICATION* 1. Name of Business DBA AS SHOWN ON INVOICES AND ADVERTISEMENTS 2. Name of Corporation AS FILED WITH THE OFFICE OF THE CALIFORNIA SECRETARY OF STATE* MUST ALSO BE ON INVOICE* 4. Business Address Number and Street Suite or Unit 3. Corporation Number City State Zip Code NOTE If this is a multiple facility address you must include the unit/suite number. 5. Mailing Address 6. Business Area Code and Telephone Number 7. List all Owners Partners Corporate Officers Directors Members Trustees Responsible Managing Employee RME and other persons who directly or indirectly control or conduct the business. Attach additional pages if necessary. Enter full legal names NO INITIALS* If a legal name contains initials only so state. If a PARTNERSHIP list all Partners. If a CORPORATION list all Officers and Directors. The list must include the Chief Executive Officer i*e* President Secretary and Chief Financial Officer i*e* Treasurer. If the same person holds all corporate offices you must so state on the application* If a TRUST disclosure is required and you must list all Trustees. Under Business and Professions Code Section 9884 an automotive repair dealer shall identify the owners directors officers partners and managers. See Instructions Sheet Page 4 Number 7 regarding FEIN/SSN requirements Full Name Last Social Security Number Home Address Middle Federal Employer I. Applicant s Background Pertains to each person listed in number 7. Attach additional pages if necessary. a CRIMINAL CIVIL VIOLATIONS Pursuant to Business and Professions Code Sections 480 and 490 has any person listed in number 7 ever been an Owner Partner Corporate Officer Member Director Trustee or Responsible Managing Employee of a Sole Proprietorship Partnership Corporation Limited Liability Company or Limited Partnership which has been convicted of any offense or entered a plea of nolo contendere in this or any other state in the United States YES NO Has any person listed in number 7 ever have/had a smog check technician or lamp/brake adjuster license issued by the this or any state in the United States Responsible Managing Employee of a Sole Proprietorship Partnership Corporation Limited Liability Company or Limited Partnership that had an automotive repair dealer registration smog check station license lamp and/or brake station license STAR certification issued by the Bureau of Automotive Repair BAR denied suspended revoked placed on probation or been issued a citation registration/license number.