mike sullivan - Harris County Tax Office

MIKE SULLIVAN
Tax Assessor-Collector
Application for Motor Vehicle Title Service License
Pursuant to Texas Administrative Code: Title 43, Part 5, Chapter 95, Rule 95.1, individuals wishing to complete an application
to register as a Motor Vehicle Title Service MUST apply in person at the Harris County Administration Building at:
1001 Preston, Room 100, Houston, Texas 77002.
NOTE: Incomplete applications or applications with false information WILL NOT be processed and the application fee will be forfeited.
You are required to notify us immediately of any changes that would interfere with your Motor Vehicle Title Service License.
Owner Information
Business Name (Attach copy of Articles of Incorporation or Assumed Name Certificate, DBA.)
Business Location - Address #1 (Physical Address of each office from which the applicant will conduct business.)
Street:
City:
State:
Zip:
County:
Business Location - Address #2 (Physical Address of each office from which the applicant will conduct business.)
Street:
City:
State:
Zip:
County:
Mailing Address (If different from above)
Street or P.O. Box:
City:
State:
Zip:
County:
Business Phone
Business Alternate Phone
Business Email Address
( )
( )
Full Legal Name of Applicant (First, Middle, Last)
Applicant Residence Address (If different from above)
Street:
City:
Applicant Phone
Alternate Phone
( )
( )
Date of Birth (MM/DD/YY)
Social Security Number
Federal Tax ID Number
State:
Zip:
Applicant Email Address
County:
Valid Texas DL or ID Number
Expiration Date
State Sales Tax Number
Please list below each individual and entity holding ownership in this business. Attach additional pages if necessary.
1. Full Legal Name of Applicant (First, Middle, Last)
Title
Phone
( )
Residence Address (If different from above.)
Street:
City:
State:
Zip:
County:
Date of Birth (MM/DD/YY)
Social Security Number
Valid Texas DL or ID Number Expiration Date
2. Full Legal Name (First, Middle, Last )
Title
Phone
( )
Residence Address (If different from above.)
Street:
City:
Date of Birth (MM/DD/YY)
Social Security Number
State:
Zip:
Valid Texas DL or ID Number
County:
Expiration Date
3. Full Legal Name (First, Middle, Last )
Title
Phone
( )
Residence Address (If different from above.)
Street:
City:
Date of Birth (MM/DD/YY)
Social Security Number
State:
Zip:
Valid Texas DL or ID Number
County:
Expiration Date
TS-1
www.hctax.net
Rev. 4/16 v3
Application for Motor Vehicle Title Service License
License Information
Type of License
New License
Renewal License
Type of Company
Individual
Limited Liability Partnership
Partnership
Corporation
YES
NO
Are you a United States citizen?
YES
Limited Partnership
Limited Liability Corporation
NO
If NO, are you a legal resident?
If you are a non-legal resident, what is your INS number?
Background Information
If yes:
NO
YES
NO
YES
YEAR
3. Have you ever been refused a Motor Vehicle Title Service License or Runner’s License? NO
YES
YEAR
NO
YES
YEAR
NO
YES
NO
YES
1. Have you ever applied for a Motor Vehicle Title Service License before?
2. Have you ever had a Motor Vehicle Title Service License or Runner’s License revoked or
suspended?
4. Have you now or in the past 5 years, been under court supervision through probation,
parole or deferred adjudication for any criminal offense or crime of moral turpitude?
5. Have you ever been finally convicted for any felony offense or any offense involving
moral turpitude?
6. Do you currently owe the county any tax, fine, or fee?
If yes, you may not be eligible to conduct business with Harris County until cleared.
YEAR
If yes:
If yes:
If yes:
If yes:
DATE
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DEPARTMENT:
%DQN Information
Bank Name
Account Number
Contact Person
Contact Phone
I swear and affirm that all the information I have provided in this application is true and accurate to the best of my
knowledge. By signing this document, I willfully give permission for Harris County Tax Office and local law
enforcement agencies to conduct a criminal background check.
Applicant Signature:
Date:
Warning: Falsifying information on any required statement or government document is a criminal offense and is
punishable by fine and/or imprisonment.
Please submit application to the Harris County Tax Assessor-Collector’s office and present the following documents:




TS-1
Your valid Texas Drivers’ License or Texas Identification Card (originals)
Your Social Security Card (original)
A photo of the physical location of your Title Service, including the sign with your company name
Articles of Incorporation listing all officers or Assumed Name Certificate (DBA)
www.hctax.net
Rev 4/16 v3