C.M.R. 29, 250, Bureau of Motor Vehicles, ch. 110, app 250-110-A
Department of the Secretary of State
Bureau of Motor Vehicles
Matthew Dunlap Patty A. Morneault
Secretary of State Deputy Secretary of State
Garry Hinkley
Director of Vehicle Services
Application to become
A Non-governmental Registration Agent
I/we hereby make application to become a Bureau of Motor Vehicles non-governmental registration agent pursuant to 29A MRSA section 204. I/we have read and agree to BMV' "Non-governmental Registration Agent Requirements" rule.
Application date:_______________
Contact person:______________________________
Company name:______________________________
Federal Identification Number:______________________________
Telephone number:_______________ Email address:_______________
Physical Address:______________________________
Mailing address:______________________________
Company officers/owners: (list at least the president and secretary, and any owner with at least 20 percent ownership.) Please include either a DOB or driver license number for each person.
_____________________________________________
_____________________________________________
List the name(s) of each person (including a DOB or driver license number) to be trained and designated as an authorized agent.
(This is the person who will hold the authorization, and will be responsible for the preparation and submission of all work.)
1._____________________________________________
2._____________________________________________
3._____________________________________________
4._____________________________________________
5._____________________________________________
Indicate the level of authorization desired.
___ Annual trailers
___Long term trailers
___ Motor Vehicles
________________________________________________________________
(Signed) (Date)
_________________________________________________________________
Printed Name & Title
C.M.R. 29, 250, Bureau of Motor Vehicles, ch. 110, app 250-110-A