Form Obl292 "Vehicle Registration Program Application for Participation" - Nevada

Form OBL292 or the "Vehicle Registration Program Application For Participation" is a form issued by the Nevada Department of Motor Vehicles.

Download a PDF version of the Form OBL292 down below or find it on the Nevada Department of Motor Vehicles Forms website.

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Occupational and Business Licensing
555 Wright Way
Carson City, Nevada 89711
(775) 684-4690
www.dmvnv.com
VEHICLE REGISTRATION PROGRAM APPLICATION FOR PARTICIPATION
Emission Station
Dealer
Business Name
Business License No.
DBA Name
FEIN
Mailing Address
Street
City
State
Zip
Physical Address
Street
City
State
Zip
Email Address
Business Phone No. (
)
-
Other Business Phone No. (
)
-
Principal’s Name(s)
Please list all employees of this business that will be processing registration transactions. If the employee holds an
occupational license, please list their department assigned occupational license number.
Name
Occupational License No.
Do you currently hold any other business or occupational license issued by the Nevada Department of Motor Vehicles?
Yes
No
If Yes, please provide the license number
Has any person listed on this application ever had a business or occupational license revoked, canceled, suspended, or
denied?
Yes
No
If Yes, please provide the following information:
Business Name
County and State Licensed
County
State
Date revoked, canceled, suspended, or denied
Has any administrative action ever been taken against the owner(s) of this business by the Department of Motor Vehicles?
Yes
No
If Yes, please provide the cause for action and the date the action was taken.
OBL292 (10/2011)
Print Form
Occupational and Business Licensing
555 Wright Way
Carson City, Nevada 89711
(775) 684-4690
www.dmvnv.com
VEHICLE REGISTRATION PROGRAM APPLICATION FOR PARTICIPATION
Emission Station
Dealer
Business Name
Business License No.
DBA Name
FEIN
Mailing Address
Street
City
State
Zip
Physical Address
Street
City
State
Zip
Email Address
Business Phone No. (
)
-
Other Business Phone No. (
)
-
Principal’s Name(s)
Please list all employees of this business that will be processing registration transactions. If the employee holds an
occupational license, please list their department assigned occupational license number.
Name
Occupational License No.
Do you currently hold any other business or occupational license issued by the Nevada Department of Motor Vehicles?
Yes
No
If Yes, please provide the license number
Has any person listed on this application ever had a business or occupational license revoked, canceled, suspended, or
denied?
Yes
No
If Yes, please provide the following information:
Business Name
County and State Licensed
County
State
Date revoked, canceled, suspended, or denied
Has any administrative action ever been taken against the owner(s) of this business by the Department of Motor Vehicles?
Yes
No
If Yes, please provide the cause for action and the date the action was taken.
OBL292 (10/2011)
Emission Station Only:
Has any principal of this business ever been convicted of felony Deceptive Trade Practices or felony Embezzlement?
Yes
No
If Yes, please provide the following information:
Full Name
Charge
Date of Conviction
State
County
If more space is needed, please use additional sheets.
Dealer Only:
Has any employee of this business ever been convicted or pleaded nolo contendere to a felony or gross misdemeanor or a
misdemeanor in violation of the provision of NRS 482 and NAC 482?
Yes
No
If Yes, please provide the following information:
Full Name
Charge
Date of Conviction
State
County
If more space is needed, please use additional sheets.
CERTIFICATE OF APPLICANT FOR PROGRAM LICENSING
Please initial next to each statement as acknowledgment that you have read and agree to all requirements of this program.
I agree to maintain a secure place of business with storage for secure supplies to restrict unauthorized
access.
I agree to comply with all requirements set forth in Nevada Revised Statutes and Nevada Administrative
.
Code pertaining to the program
VERIFICATION
I, (we), the undersigned hereby certify that under penalty of perjury, that I (we) am the applicant making the foregoing
application, and that the application has been read and the contents thereof and all statements contained herein are true,
correct and complete to the best of my knowledge and belief.
Signed
Date
State of Nevada
County of
Subscribed and sworn before me this
day of
, 20
Notary Public or Authorized Nevada DMV Representative
(Notary Seal)
Application Accepted By:
Reviewed By:
Approved:
Yes
No
Reason for Denial:
OBL292 (10/2011)
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