Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette

Road North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198
PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

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Application for Manufactured Home Limited Dealer License for Selling Used Manufactured Homes

.

NOTE: Application must be accompanied by: 1. 2. 3. 4. $100.00 Fee - check or money order payable to: Department of Labor and Industry $5,000.00 Surety Bond (on furnished form only!). Copy of Park License issued from the Department of Health. If your business is a corporation or a partnership, we need a photocopy of the Certification of Incorporation or Proof of Partnership.

Notice to all applicants: Data furnished on this form will be used to assess qualifications for limited licensure. You are not legally required to provide this data, except for the telephone numbers. If you fail to provide the legally required data the Department of Labor and Industry will be unable to grant a Limited Dealer License. After issuance of a license, all legally required information submitted on this application, except the applicant’s social security number, is public data. The Department may use the social security number for revenue recapture as authorized by M.S. Chapter 327A and for identification purposes. M.S. § 270.72, subd. 4, requires you to supply your Minnesota business tax identification number and your social security number. M.S. § 176.182 also requires information regarding workers’ compensation insurance. Failure to disclose any material information or providing false or misleading statements with respect to any material fact required herein is cause to deny, suspend or revoke limited license. In compliance with the provisions of Minnesota Statutes regulating Limited Dealers, I am applying for a Limited Dealers License authorizing me to engage in business as a manufactured home Limited Dealer. SECTION I
NAME OF PARK OWNER/MANAGEMENT COMPANY BUSINESS PHONE

NAME OF PARK (as it appears on the Manufactured Home Park License)

PARK ADDRESS (number and street)

COUNTY

CITY

STATE

ZIP CODE

MN BUSINESS TAX ID NO.

SECTION II 1. When the Applicant is not an individual, the Applicant’s name must be an officer or managing partner of the corporation or partnership. 2. If you are using a trade name which is part of a corporation, such as Super Homes, Inc., d/b/a XYZ Manufactured Home Park, both names must be shown on the application and surety bond. 3. If your business name is other than your first and last name and middle initial, furnish proof of filing an assumed name with the Secretary of State. Their address and phone number is: Minnesota Office of the Secretary of State, 180 State Office Building, 100 Rev. Dr. Martin Luther King Jr. Boulevard, St. Paul, MN 55155-1299, 651-296-2803, Greater MN toll free: 1-877-551-6767, public.information@state.mn.us, Fax: 651-297-7067, TTY: 1-800-627-3529, http://www.sos.state.mn.us
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

Office Use Only

DATE RECEIVED

DATE ISSUED

PAID CHECK NO.

LICENSE NO.

MS0516 (4/07)

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APPLICANT NAME

POSITION OR TITLE

SOCIAL SECURITY NUMBER

BUSINESS ADDRESS

CITY

STATE

ZIP CODE

HOME ADDRESS

CITY

STATE

ZIP CODE

SECTION III PROOF OF IDENTITY Attach photocopy of current Minnesota Driver’s License or other current identification showing photo and signature, within dotted lines at right.

A COPY OF THIS APPLICATION AND ACCOMPAYING DOCUMENTS SHALL BE KEPT IN YOUR LIMITED DEALER FILE. SECTION IV
WORKERS’ COMPENSATION INSURANCE COMPANY POLICY NUMBER

INSURANCE AGENT’S NAME

TELEPHONE NUMBER

ADDRESS

CITY

STATE

ZIP CODE

DATES OF COVERAGE (starting date)

THROUGH: (ending date)

OR I certify that I am not required to carry Workers’ Compensation Insurance because: I am a sole proprietor or partner and I have no employees. I have no employees who are covered by the Workers’ Compensation Law. Note: Only employees exempt by statute (spouse, parent and children) are not covered by the Workers’ Compensation Law. I understand that the information provided above would be verified by the Department of Labor and Industry, and that I am subject to a $1,000 penalty if the information provided is false. I certify that the information provided on this application is true, accurate and complete.
SIGNATURE DATE
(check one)

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Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198 BOND NO.
PRINT IN INK or TYPE

Manufactured Home Limited Dealer Bond

AMOUNT

EFFECTIVE DATE

$5,000

Pursuant to the terms of this instrument
(Business name as registered with the Office of the Secretary of State)

with its principal office located at
(Street address, City, State, Zip Code, phone number)

and in the State of Minnesota, with its main office located at:

a corporation licensed to transact a surety business
(Street address, City, State, Zip Code)

as Surety, their successors, assigns, and legal representatives are held and firmly bound, jointly and severally, to the State of Minnesota and any third party sustaining injury within the terms of this bond for payment in the amount of FIVE THOUSAND DOLLARS ($5,000), as provided in M.S 327B.11. This bond is exclusively for the purpose of reimbursement of consumer customer claims, pursuant to M.S. 327B.11. The condition of this obligation is that the Principal has applied for a Manufactured Home Manufactured Home Dealer’s license to be issued upon the furnishing of this bond, if the Principal faithfully complies with all of the statutes of the State of Minnesota, regulating or being applicable to the business of the Principal as a manufacturer of manufactured homes or being applicable to the business of the Principal as a dealer in manufactured homes, and indemnifies any person dealing or transacting business with the Principal in connection with any manufactured home from any loss or damage occasioned by the failure of the Principal to comply with any of the laws of the State of Minnesota, then no obligation under this bond shall accrue; otherwise, this obligation shall remain in full force and effect. The terms of this bond shall be continuous and shall constitute a new obligation in the sum of $5,000 for each annual license period for which the Principal is licensed, provided, however, that the aggregate liability for the Surety to all persons for any one annual license period shall in no event exceed the sum of $5,000. The Surety Company shall notify the Department of Labor and Industry, Construction Codes and Licensing Division, in writing prior to payment of any claim against this bond. If, within 10 days of receipt of notification, the Department of Labor and Industry does not object in writing, the claim may be paid. M.S. 317B.11, Subd. 2. This bond may be canceled by the Surety, as to future liability, by giving written notice by Certified Mail, addressed to the Principal at the address as stated in this bond, and to the Department of Labor and Industry, Construction Codes and Licensing Division, 443 Lafayette Road No., St. Paul, MN 55155-4341. Thirty (30) days after the mailing of that notice, this bond shall be null and void as to any liability thereafter arising, the Surety remaining liable, however, subject to all the terms, conditions, and provisions of this bond, for any and all acts covered by this bond up to the date of the cancellation. APPLY INSURANCE Signed and Witnessed this day of COMPANY SEAL

PRINCIPAL

WITNESS TO PRINCIPAL SIGNATURE

SIGNATURE AND TITLE

SURETY COMPANY

WITNESS TO SURETY SIGNATURE MS0517 (5/06) 1 of 2

SURETY COMPANY REPRESENTATIVE SIGNATURE AND TITLE

(INDIVIDUAL ACKNOWLEDGEMENT)
STATE OF COUNTY OF On this day of } } } ss. before me, a Notary Public within and for said county, personally appeared

to me known to be the person described in and who executed the foregoing instrument, as Principal, and acknowledged to me that the execution of this instrument was a voluntary act and deed. (SEAL) Notary Public, My Commission Expires County,

(ACKNOWLEDGEMENT OF PARTNERSHIP)
STATE OF COUNTY OF On this day of } } } ss. before me, a Notary Public within and for said county, personally appeared

known to me to be a partner in the partnership whose name is subscribed on this bond form, who acknowledged to me that this bond was executed on behalf of the partnership for the purposes therein contained. (SEAL) Notary Public, My Commission Expires County,

(CORPORATE ACKNOWLEDGEMENT)
STATE OF COUNTY OF On this day of } } } ss. before me, a Notary Public within and for said county, personally appeared , who being first duly sworn, says that he/she is the of , Principal herein, and executed the foregoing instrument for and in its behalf, by authority of its Board of Directors; that the seal affixed to the foregoing instrument is the corporate seal of said corporation; and further acknowledged said instrument and the execution thereof to be the voluntary act and deed of said corporation. (SEAL) Notary Public, My Commission Expires County,

(SURETY ACKNOWLEDGEMENT) (Corporate Officer)
STATE OF COUNTY OF On this day of of } } } ss. before me, a Notary Public within and for said county, personally appeared , who being first duly sworn, says that he/she is the , Surety herein, a corporation duly organized and existing under laws of the State of , and executed the foregoing instrument for and in its behalf, by authority of its Board of Directors; that the seal affixed to the foregoing instrument is the corporate seal of said corporation; and further acknowledged said instrument and the execution thereof to be the voluntary act and deed of said corporation. (SEAL) Notary Public, My Commission Expires This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
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County,

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198

Manufactured Home Limited Dealer Surety Bond Important Notice Regarding Insurance Company Claim Contact Information (Required)

The following information must be furnished with the bond. The address and telephone number noted must be the location where claims against the bond can be filed, and when applicable, the address of the company’s agent in Minnesota. BOND NO. PRINT IN INK or TYPE Check one: Company Office Attorney in Fact Minnesota Agent

BOND COMPANY NAME

CONTACT PERSON NAME

TELEPHONE NO.

ADDRESS

CITY

STATE

ZIP CODE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

MS0517 Attachment (5/06)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing \ Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198
PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

Manufactured Home Duplicate Construction Seal Application

INSTRUCTIONS: Complete the following information. Sign and date the application, and submit a check or money order payable to Department of Labor and Industry in the amount of $30.00 plus $3.50 for shipping and handling for a total of $33.50. Must accompany (MS001)24 item Code Non-Compliance Checklist (4 pages) with photocopy of title of house. Application submitted by:
APPLICANT NAME

Owner

Licensed Dealer

Other ____________________________
APPLICANT TELEPHONE NO.

APPLICANT STREET ADDRESS

APPLICANT CITY

STATE

ZIP CODE

Complete the Owner’s Information ONLY if different from Applicant Information
OWNER NAME OWNER TELEPHONE NO.

OWNER STREET ADDRESS

OWNER CITY

STATE

ZIP CODE

LOCATION OF HOME: (include Park name)

MANUFACTURER NAME

DATE OF MANUFACTURE

SERIAL NUMBER

MISSING SEAL OR LABEL NO.

INSTALLATION DATE

INSTALLATION SEAL NO.

DIMENSIONS (actual dimension, not including hitch, drawbar and extensions) Single Wide: ________ X ________ Double Wide: _______ X ________

INDEPENDENT AGENCY NAME AND LABEL NO. (UL, PRS, etc.)

This home has no known building code violations and it has not been altered. All information as submitted is true and correct to the best of my knowledge. The seal or label, when received, will be affixed to this home by me near the exterior left rear corner of the home, about one foot above the floor line.
APPLICANT SIGNATURE DATE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. CHECK DATE Office Use Only CHECK # AMOUNT

MS0515 (5/06)