304-926-0705 • dmv.wv.gov
Mail Applications and Fees to: Dealer Services
PO Box 17100 • Charleston, WV 25317
West Virginia Department of Transportation
Division of Motor Vehicles
Dealer Renewal Application
Dealer License Number:
Mailing Address:
STREET ADDRESS CITY COUNTY STATE ZIP
STREET ADDRESS CITY STATE ZIP
STREET ADDRESS CITY STATE ZIP
STREET ADDRESS CITY STATE ZIP
STREET ADDRESS
NAME
NAME
NAME
PHONE NUMBER
PHONE NUMBER
PHONE NUMBER CITY STATE ZIP
STREET ADDRESS CITY STATE ZIP
Repair Facility Name:
STREET ADDRESS CITY STATE ZIP
Business Address:
STREET ADDRESS CITY COUNTY STATE ZIP
Dealership Name:
Telephone Number
( )
Detailed Dealer Questionnaire
1. Any dealership changes pursuant to
§
17A-6-9 since the last renewal? No Yes •
2.
3. List any additional locations of operation for your dealership.
*Attach addendum if necessary.
5.
4. List business name and address of the repair facility servicing vehicles for the dealership. Write “NA” if repair facility address is same as dealership.
If “yes,” submit form MV-126-M-DS with this application.
THIS APPLICATION MUST BE TYPEWRITTEN OR PRINTED LEGIBLY IN BLUE OR BLACK INK AND SUBMITTED BEFORE JUNE 1
ST
.
CONTINUED ON NEXT PAGE
WRECKER
DIS
M
ANTLER
DEALER
RECREATIONAL
DEALER
AUTO AUCTION
MOTORCYCLE
DEALER
MOBILE HOME (A)
AND
TRAILER DEALER (B)
_____First
Special Demo Plate
for $100.00
_____Additional
Special Demo Plate(s)
at $50.00 each
WD Plates-Towing
#_______________
DEMO/Only One
______________
at $25.00 Each
_____more Locations
at $1.00 per each
_____more Locations
at $1.00 per each
_____more Locations
at $1.00 per each
_____more Locations
at $1.00 per each
_____more Locations
at $1.00 per each
_____more Locations
at $1.00 per each
N/A
N/A
N/A
N/A
N/A
_____________
Additional Plat
es
at $25.00 each
_____________
A
dditional Plat
es
at $25.00 each
____________
A
dditional Plat
es
at $5.00 each
___________
A
dditional Plat
es
at $5.00 each
_________ Plates per
Formula at $5.00 each
____________Exempt
Plates at $5.00 each
One Plate and
$100.00
License
$15.00
Four Plates and
$100.00
One Plate and
$100.00
Two Plates and
$10.00
Four Plates and
$25.00
(A) EXEMPT ($0)
(B) $150.00
$150.00
$150.00
EXEMPT ($0)
EXEMPT ($0)
$150.00
Recovery Fund
Total Fees Due
FEES DUE
Required Plates
and License
Additional
Plates
Additional
Special Demo
Plates
NEW CAR DEALER
AND USED CAR
DEALER
MANUFACTURER
TRANSPORTER
FINANCIAL INSTITUTION
$ $ $ $ $ $
FEE SCHEDULE
Telephone Number:
( )
Telephone Number:
( )
( )
( )
( )
DMV-126-E-DS Pg 1 of 2 Rev. 03/2023
11. Please provide a valid
e-mail address
for all electronic communications:
12. A personal property tax receipt for the dealership for the prior calendar year must be included with this application. If no taxes
9.
Continued Detailed Dealer Questionnaire
10. obligation
within the last year?
SIGNATURE OF DEALER DATE
/
(X)
/
I hereby state and certify the statements made within this application are true and correct to the best of my knowledge and belief under penalty of
false swearing. West Virginia Motor Vehicle Law §17A-6-6.
No Yes, the following is the date, court, and location:
No Yes, the following is the date, court, and location:
Name:
Name:
Name:
Name:
Name: Name:
STREET ADDRESS CITY STATE ZIP
6. List names of individuals authorized to transact business on behalf of the dealership.
7. Liability insurance pursuant to
§
17A-6-4, must be submitted with application.
Address:
NAIC Number:
Policy Number:Insurance Company Name:
Insurance Agent Name:
Telephone Number:
( )
STREET ADDRESS CITY STATE ZIP
STREET ADDRESS CITY STATE ZIP
Agent Address:
STREET ADDRESS CITY STATE ZIP
Agent Address:
Local Agent Name:
Telephone Number:
( )
8. Bond pursuant to
§
17A-6-4, DMV Form 126-DS-P, Bond must be submitted with application along with a Power of Attorney.
Bond Company Address:
Bond Company Name:
Bond Number:
DMV-126-E-DS Pg 2 of 2
