Form VD-164 template
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Applicant Authority to Release Information
To allow the DMV authority to perform a dealer license background check and release of information.
The document is a dealer license application to the Vermont Department of Motor Vehicles. The applicant provides their full name, SSN, date of birth, place of birth, sex, mailing and legal addresses, telephone numbers, and any aliases. They answer questions about criminal convictions for extortion, forgery, fraud, larceny or embezzlement, violations of dealer laws or regulations, willful intent to commit fraud or misrepresentation, and history of insufficient funds checks within the past five years. The applicant authorizes the Commissioner of Motor Vehicles to review their checking accounts and obtain information from credit reports, corporation names, Tax Department information, and law enforcement records.
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