Certification of Distributor - Wisconsin Department of ...
lefttop00MANUFACTURER’S OR IMPORTER’S CERTIFICATION OF DISTRIBUTORWisconsin Department of TransportationMV2241 3/2018Date FORMTEXT ?????TO:Dealer Licensing SectionWisconsin Department of Transportation4822 Madison Yards WayP.O. Box 7909Madison, WI 53707-7909Distributor (Full Name) FORMTEXT ?????Manufacturer or Importer Name FORMTEXT ?????Street Address FORMTEXT ?????Street Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip Code FORMTEXT ?????City FORMTEXT ?????Statewide Sole Distributor FORMCHECKBOX Yes FORMCHECKBOX NoState FORMTEXT ?????Zip Code FORMTEXT ?????Country FORMTEXT ?????Effective Contract Date FORMTEXT ?????Make of Motor Vehicle(s) Represented/Distributed FORMTEXT ?????Assigned Sales Area (Name Counties/ Describe Locality. If statewide, check box above.) FORMTEXT ?????This is to certify that the above named distributor and the above named manufacturer or importer have executed a contract effective on the stated date, subject to the licensing provisions of Chapter 218, Wisconsin Statutes, for the representation and distribution of the specified make(s) of motor vehicle(s) in the identified counties/localities within Wisconsin. FORMCHECKBOX A copy of such contract is attached for filing as required by law. FORMCHECKBOX All our contracts with all Wisconsin distributors are identical; a blanket contract is filed as required by law.Authorized Agent of Manufacturer/Importer FORMTEXT ?????Position FORMTEXT ?????Office Address FORMTEXT ?????(Authorized Agent of Manufacturer/Importer Signature)NOTE:In case of termination or cancellation, Wisconsin Statutes require that a written notice be given to the distributor, which includes the effective date and specific grounds for termination or cancellation, at least 60 days prior to the effective date, and a copy of such notice is filed with the Wisconsin Department of Transportation. ................
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