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Utah State Tax Commission
Motor Vehicle Enforcement Division
210 N 1950 W, Salt Lake City, UT 84134
TC-760
(801) 297-2600 • www.tax.utah.gov
Application for Representative License Rev. 4/04
Renewal/ New Application
FEE: $26
Representative
First name Middle name Last name License number
Home address City State ZIP Code
Home telephone number (include area code) Social Security Number Date of birth
I hereby apply for a new/renewal Representative License for the year July 1, __________ through June 30, __________.
I do solemnly swear (or affirm) that the statements contained in the forgoing are true and correct.
Signature of applicant Date
Form must be signed before submitting.
Employer
Business name License number
Business owner's name (PRINT) Position
The above applicant is currently employed by this firm; and, I certify that the information contained in the foregoing
application is true and correct to the best of my knowledge and belief. I recommend the applicant to be licensed as a
representative in the State of Utah.
Signature of owner Date
Form must be signed before submitting.
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