Fill and Sign the Filled Medical Certificate Sample Form

STATE OF TENNESSEE DEPARTMENT OF COMMERCE & INSURANCE AUCTIONEER COMMISSION 500 JAMES ROBERTSON PARKWAY NASHVILLE, TN 37243-1152 Phone: (615) 741-3600 Fax: (615) 253-1179 www.tn.gov/commerce/boards/auction (Questions 1 through 12 must be answered or application will be returned) APPLICATION FOR FIRM LICENSE 1. Business name in which license will be issued and advertising will be conducted. ________________________________________________________________________ a) Mailing address _______________________________________________________ (Street & Number) (City) (State) (Zip Code) b) Physical address _______________________________________________________ (Street & Number) (City) (State) (Zip Code) c) Business address _______________________________________________________ (Street & Number) (City) (State) (Zip Code) d) Phone __________________ Fax __________________ E-Mail _________________ 2. Is applicant a corporation ___, partnership ___, association ___, company ___, or proprietorship ___ (individual) 3. If corporation, indicate state in which incorporated __________________ (attach charter) (State) Branch office(s) address(es), if any ___________________________________________ 4. Will firm be engaged in auction business exclusively? NO _____ YES _____ 5. State name of all persons interested in the business as principals, officers, directors, or managing agents. State the capacity (title) of each. Name Capacity (title) ________________________________________________________________________ ________________________________________________________________________ 6. List all auctioneers and apprentices (include TN Auctioneer License #’s) who are to be affiliated with your firm. Indicate status, whether apprentice or auctioneer. Name License No. Status ________________________________________________________________________ ________________________________________________________________________ 7. Has applicant ever engaged in auction activities in this state or any other state? NO _____ YES _____ If Yes, Where? _______________________When ___________ 1 8. Has any partner, officer, or director ever been indicted or convicted on charges involving embezzlement, obtaining money under false pretenses, larceny, or extortion? NO ______ YES _____ (If YES, attach all court documentation and a letter of explanation). 9. Are there any civil suits or judgments pending against any partner, officer or director at this time? NO _____ YES _____ (If YES, attach all court documentation and a letter of explanation). 10. Has any partner, officer, or director ever had an auctioneer’s license, real estate broker’s or any other type of occupational license suspended, revoked, refused or disciplined by this State or any other State? NO _____ YES _____ (If YES, attach a letter of explanation). Where? ________________________________________________________________________ 11. Does the principal auctioneer for the firm understand and accept that he will be held accountable for all professional actions of all members and employees of the firm when operating within the scope of their professional activities? 12. If non-auctioneer firm owner(s), list name(s) and date exam passed Name Date ________________________________________________________________________ ________________________________________________________________________ AFFIDAVIT (Read Carefully) The undersigned by submitting this application to the Tennessee Auctioneer Commission for a license to carry on the business under the provisions of the Auctioneer’s License Act of 1967, as amended, swears (or affirms) that he or she has read and is thoroughly familiar with the provisions of the aforementioned Act, and agrees to fully comply with them. The undersigned further swears (or affirms) that all of the information given in this application is true to the best of his or her knowledge and belief. __________________________________ ____________________________________ Signature: Owner(s) of Business Signature of Licensed Auctioneer __________________________________ Print Name(s) ____________________________________ Print Name Subscribed and sworn to before me this _____ of __________, ______ Day Month Year My Commission expires ___________, _____, ______ Month Day Year _____________________________________________ Notary Public (SEAL) ________________________ County State SEAL IS MANDATORY IN-0413 2 STATE OF TENNESSEE DEPARTMENT OF COMMERCE & INSURANCE AUCTIONEER COMMISSION 500 JAMES ROBERTSON PARKWAY NASHVILLE, TN 37243-1152 Phone: (615) 741-3600 Fax: (615) 741-1245 www.tn.gov/commerce/boards/auction Pursuant to Tennessee Code Annotated §62-19-112(b)(4), the Tennessee Auctioneer Commission may suspend, revoke or refuse to renew any license issued by the Commission for failure to keep or maintain any money belonging to others in an escrow or trustee account. Accordingly, please complete the following: _______ The undersigned does handle funds belonging to others or intends to do so in the future. PLEASE HAVE YOUR BANK COMPLETE THE FOLLOWING AND RETURN TO THIS OFFICE. Firm/Auctioneer or Gallery Name and Address: _________________________________ Escrow Account Number: __________________________________________________ Bank name / address / telephone number: ______________________________________ ____________________________________ Bank Officer Signature Date I hereby certify that the foregoing information is true and correct to the best of my knowledge. I further understand that I have a continuing duty to notify the Commission in the event that any of the information contained herein changes. The Tennessee Auctioneer Commission, or its agent/designee, is hereby authorized to audit any escrow account(s) reference above. _______________________________________________________________________ Auction Firm/Gallery Owner and Escrow Account Holder (Please Print) By: _______________________________________________________________________ (Authorized Signature) (Printed Name) (Date) Notary Public: __________________________________________ (SEAL) My Commission Expires: _________________________________ 3 TENNESSEE AUCTIONEER COMMISSION Licensing Fees Apprentice Initial License Fee - Application Fee License Fee Recovery Fee $ $ $ $ 50.00 125.00 50.00 225.00 Auctioneer Initial License Fee - Application Fee License Fee Recovery Fee $ $ $ $ 50.00 175.00 50.00 275.00 Firm Initial License Fee - Application Fee License Fee Recovery Fee $ $ $ $ 50.00 125.00 50.00 225.00 Firm Branch Initial License Fee - Application Fee License Fee Recovery Fee $ $ $ $ 50.00 75.00 50.00 175.00 Gallery Initial License Fee - Application Fee License Fee Recovery Fee $ $ $ $ 50.00 175.00 50.00 275.00 Gallery Branch Initial License Fee - Application Fee License Fee Recovery Fee $ $ $ $ 50.00 75.00 50.00 175.00 Public Automobile Auctioneer License Fee - Application Fee License Fee $ $ $ 50.00 175.00 225.00 Public Automobile Auction Firm License Fee - Application Fee License Fee $ $ $ 50.00 175.00 225.00 If you are reciprocating from another state- please check the reciprocal license fees. 4