License Bond Application

Full company name including D/B/A

Company Type

Corporation LLC Partnership Sole Proprietorship

Company Phone Number

Company Email Address

Business Street Address

Business County

City

State

Zip

1. Has the company ever had a bond claim?

Yes NO

2. Does the company have any active bonds with another agency?

Yes NO

3. Has the company ever been declined a bond?

Yes NO

4. Has the company ever had a bond cancelled?

Yes NO

5. Has your company or any of its principals ever petitioned for bankruptcy or failed in business?

Yes NO

5. Has your company or any of its principals ever petitioned for bankruptcy or failed in business?

Yes NO

6. Does applicant have any unresolved litigation or judgments?

Yes NO

7. Have any owners/partners/stockholders/members ever had an arrest, indictment, imprisonment or conviction involving dishonesty or fraud?

Yes NO

8. Has applicant had any business license suspended, revoked or denied or been the subject to any legal/administrative proceedings resulting in disciplinary action?

Yes NO

9. Has the Company been a party to a Surety Bond claim?

Yes NO

10. Has the Company, any predecessor company or any owner ever had a tax lien exceeding $1,000?

Yes NO

11. How many years has the Applicant been in business?

12. If a new start up, how many years of experience does the Applicant have in the motor vehicle dealer industry?

Owner 1

Applicant's Legal Name

Email Address

Contact Phone Number

Date of Birth

Social Security Number

Single or Married

Single Married

Residence Address

City

State

Zip

U.S. Citizen

Yes No

Percentage of Ownership

Spouse Name

Spouse Social Security Number

Spouse Date of Birth

Owner 2

Applicant's Legal Name

Email Address

Contact Phone Number

Date of Birth

Social Security Number

Single or Married

Single Married

Residence Address

City

State

Zip

U.S. Citizen

Yes No

Percentage of Ownership

Spouse Name

Spouse Social Security Number

Spouse Date of Birth

Credit Report Consent *

The undersigned applicant(s) and/or indemnitor(s) understand and agree that by submitting an application for bonding to Ron E. Widener and Associates Inc allows our agency to shop your quote with all our bonding companies. The undersigned authorize the verfication of information provided and the obtaining of additional information from any source, including obtaining a credit report on the undersigned and/or any other individuals associated with the business involved, including spouses, at the time of application, in any review or renewal, at the time of any potential or actual claim, or for any other legitimate purpose determined by the writing company in its reasonable discretion.

I / we agree to the above.

Owner 1 Signature and Corporate Title

Owner 1 Spouse Signature and Corporate Title

Owner 2 Signature and Corporate Title

Owner 2 Spouse Signature and Corporate Title

Have you attended a State Approved Used Car Pre License Seminar?

Yes No

Would you care to register for the next class?

Yes No

Contact Reggie Widener

Motor Vehicle Dealer Services
6887 Oak Ridge Commerce Way
Austell, GA 30168
Phone: 770-941-0293
Toll Free: 800-793-5177
Fax: 770-941-3472
Reggie@RonWidener.com

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