Incomplete Or Incorrectly Completed Applications May Be Returned

INCOMPLETE OR INCORRECTLY COMPLETED APPLICATIONS MAY BE RETURNED

The Area Specialist may contact you for additional information in order to process this application for a license

Junkyard Name: ______Contact Person: ______Telephone:

Junkyard Address: ______City: ______State: ______Zip Code:

Date Junkyard Established: Assessor’s Parcel Number:

Junkyard Owner Name: Telephone:

Street Address: ______City: ______State: ______Zip Code:

Tax ID or Social Security Number (Required):

Tenant Name (If other than Owner): Telephone:

Street Address: ______City: ______State: ______Zip Code:

Location of Junkyard

The junkyard location is adjacent to Highway/Route: in County.

The junkyard is located on the (check one) RIGHT LEFT side of the road when the direction of travel is (circle one): N S E W

Distance from the nearest intersection is ______in (check one) MILES FEET

The location is (check one) BEFORE AFTER the Intersection of (give name of road) Is the junkyard located within City Limits? NO YES If yes, give City Name:

Is the property zoned INDUSTRIAL by local or county governing authority? NO YES

You must complete the affidavit on the reverse side of this form and have it notarized.

Enclose the following with your application:

_____A completed junkyard information sheet.

_____If the property is zoned, enclose a letter from the local or county zoning authority stating the zoning classification.

______If the junkyard was lawfully in existence prior to August 4, 1966 include proof of the date the junkyard was established.

_____A certified copy of the Last Deed of Record.

_____A $10.00 check or money order made payable to: “Director of Revenue, Credit State Road Fund”.

Mail the completed application, enclosures, and payment to the area specialist for the county in which the junkyard is located.

(See the back of this form for addresses)

Additional forms and information can be found at

If a license is issued, the applicant, by signature, agrees to maintain the junkyard in accordance with Sections 226.650 – 226.720 RSMo.

Furthermore, the applicant, by signature, agrees that the information provided in this application is complete and accurate.

STATE OF ______, County of ______

______, being of lawful age and first duly sworn, upon his oath deposes and states:

(Name of Applicant)

CHECK ONE:

( ) That I am the above-mentioned individual.

( ) That I am the ______of ______which is organized under the laws of

(title) (name of corporation)

______, with its principal office and place of business in ______, ______;

(state) (city, state)

and that I have the power and authority for and on behalf of said corporation to make this affidavit and in its behalf, and do so make same.

( ) That I am the ______of ______which is not a corporation and that I have

(title) (name of firm)

the power and authority for and on behalf of said firm and its members and owners to make this affidavit for in its and their behalf, and do so make same.

That I have read the foregoing and that the facts set out therein are true and correct to the best of my knowledge and belief.

______

Signature of Applicant

Subscribed and sworn to before me this ______day of ______, 20 ______.

My Commission expires: ______

Notary Public

Area 1 (816) 622-6353

Missouri Department of TransportationCounties include:Andrew, Atchison, Bates, Buchanan, Cass, Clay, Holt, Henry, Jackson, Johnson,

600 Northeast Colbern Rd.Lafayette, Nodaway, Platte, Ray

Lee’s Summit, MO 64086