INTERNATIONAL REGISTRATION PLAN
SCHEDULE A & C
TYPE OF APPLICATION REQUESTED
o NEW ACCOUNT |
o WEIGHT INCREASE |
o DUPLICATE CAB CARD |
o ADDRESS CHANGE |
o ADD VEHICLE |
o WEIGHT DECREASE |
o REPLACEMENT PLATES |
o TEMPORARY AUTHORITY |
o DELETE VEHICLE |
o RENEWAL |
o REPLACEMENT STICKER |
o OTHER____________________ |
o TRANSFER PLATES |
o FLEET TO FLEET |
o SAFETY US DOT # CHANGE |
|
REGISTRANT/CARRIER INFORMATION
1.ACCOUNT # _______________________________________ 2. FLEET # __________________________________________
3.REGISTRANT NAME: ____________________________________________________________________________________
4.DBA: __________________________________________________________________________________________________
5. |
BUSINESS ADDRESS: ____________________________________________________________________________________ |
|
|
(No P.O. Box Number Allowed) |
|
|
|
|
CITY: ______________________ STATE: _______ ZIP CODE: ______________ |
COUNTY: ______________________ |
6. |
CONTACT PERSON: ____________________________________________________________________________________ |
7. |
PHONE #: ( |
) ________________________________ |
8. FAX # ( |
) ____________________________________ |
9. |
EMAIL ADDRESS:________________________________________________________________________________________ |
|
Do you want to receive your IRP Renewal Application and IRP notices electronically rather than by mail service? o Yes o No |
10. |
TAXPAYER IDENTIFICATION # (TIN): ________________________________________________________________________ |
11. |
DATE OF BIRTH: ___________________________________ |
12. SEX: |
o M |
o F o X |
13.PRIVACY ACT: Check the INFORMATION DISCLOSURE box at the end of this sentence if you do not want your personal information from this record used for surveys, marketing and solicitations. o
14.WYOMING AUTHORITY#: _________________________________________________________________________________
15.REGISTRANT’S DOT #: __________________________________________________________________________________
Have you previously been registered in any jurisdictions? oYes |
o No, |
If yes, jurisdiction ______________________________ |
Do you lease your vehicle and driver to a motor carrier? |
oYes o No |
|
FLEET INFORMATION |
|
|
|
|
16. FLEET TYPE: ____ |
17. COMMODITY CLASS: ____ |
18. # OF REG MONTHS: ______ |
19. EFFECTIVE DATE: _______________ |
20. EXPIRATION DATE: _____________ |
21. MAILING ADDRESS: ______________________________________________________________________________________ |
CITY: ______________________ |
STATE: _______ |
ZIP CODE: ______________ COUNTY: ________________________ |
|
|
|
|
|
FLEET TO FLEET TRANSFER INFORMATION
VEHICLE IDENTIFICATION NUMBER
VEHICLE IDENTIFICATION NUMBER
REPLACEMENT
VEHICLE UNIT # (OEN)
*(Send in plates for deletion.)
WEIGHT
INFORMATION Account # ____________________________________
30.Please list the weight you want on your cab card for all jurisdictions. Canadian jurisdictions will print the weight in kilograms on the cab card.
AK |
____________________ |
KS |
____________________ |
NJ |
____________________ |
VT |
____________________ |
|
AL |
____________________ |
KY |
____________________ |
NM |
____________________ |
WA |
____________________ |
|
AR |
____________________ |
LA |
____________________ |
NV |
____________________ |
WI |
____________________ |
|
AZ |
____________________ |
MA |
____________________ |
NY |
____________________ |
WV |
____________________ |
|
CA |
____________________ |
MD |
____________________ |
OH |
____________________ |
WY |
____________________ |
|
CO |
____________________ |
ME |
____________________ |
OK |
____________________ |
AB |
____________________ (Canada) |
CT |
____________________ |
MI |
____________________ |
OR |
____________________ |
BC |
____________________ (Canada) |
DC |
____________________ |
MN |
____________________ |
PA |
____________________ |
MB |
____________________ (Canada) |
DE |
____________________ |
MO |
____________________ |
RI |
____________________ |
NB |
____________________ (Canada) |
FL |
____________________ |
MS |
____________________ |
SC |
____________________ |
NL |
____________________ (Canada) |
GA |
____________________ |
MT |
____________________ |
SD |
____________________ |
NS |
____________________ (Canada) |
IA |
____________________ |
NC |
____________________ |
TN |
____________________ |
ON |
____________________ (Canada) |
ID |
____________________ |
ND |
____________________ |
TX |
____________________ |
PE |
____________________ (Canada) |
IL |
____________________ |
NE |
____________________ |
UT |
____________________ |
QC |
____________________ (Canada) |
IN |
____________________ |
NH |
____________________ |
VA |
____________________ |
SK |
____________________ (Canada) |
|
|
|
|
|
|
|
|
|
VEHICLE INFORMATION FOR NEW ACCOUNTS, ADDITIONS, OR CHANGES
31.VEHICLE UNIT # (OEN)
A) VEHICLE IDENTIFICATION NUMBER |
|
|
|
|
B) YEAR |
C) MAKE |
D) VEHICLE TYPE |
E) FUEL/CYL |
F) WHEELBASE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G) UNLADEN WT |
H) SEATS |
I) AXLES |
|
J) COMBINED AXLES |
K) COLOR |
|
L) OWNER NAME |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M) TITLE DOC. # |
|
N) TITLE DOC. JUR. |
O) SAFETY TAXPAYER ID # (TIN) |
|
P) SAFETY US DOT # |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q) Will vehicle safety responsibility |
|
|
|
R) SAFETY NAME |
|
|
|
|
|
|
change during the year? o Yes |
o No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W) INS. CO. CODE |
X) CURRENT PLATE # |
Y) CURRENT PLATE CLASS |
Z) SPECIAL USE |
|
|
|
|
REGISTRATION |
IF THE REGISTRANT IS NOT THE OWNER, fill in the information below. Proof of ownership and proof of the |
AUTHORIZATION |
OWNER’S name and date of birth are required. |
|
|
|
|
|
|
Vehicle #1 - Owner’s Name |
|
Date of Birth |
|
Is the vehicle leased? |
|
|
|
|
|
|
|
o Yes o No |
Address |
Apt. No. |
City |
State |
Zip Code |
|
|
|
|
|
|
|
|
|
I authorize the person named in number 3 of Part 1 to register this vehicle. |
|
|
|
|
|
|
Owner’s Authorized |
|
|
|
|
|
|
|
Signature X |
|
|
|
|
Date: |
|
|
|
|
|
|
|
|
|
|
If signing for a corporation, print your full name and title here
CERTIFICATION: I, the Undersigned, certify under penalty of perjury that all information provided in this Application is true and accurate to the
best of my knowledge, and that the subject vehicle: is fully equipped, inspected, insured, and will be operated, in compliance with New York State Vehicle and Traffic Law (VTL); possesses a valid NYS inspection issued within the last twelve (12) months; or, in the alternative, has qualified for an extension of such inspection (see, DMV form VS-1077) and will be inspected within the next ten (10) days; is covered by a current policy of insurance or financial security as required by VTL; and if previously “junked”, has been repaired to conform with VTL Sections 375 and 376; possesses a currently valid NYS registration (if I am using this Application to request issuance of replacement registration documents). I declare that I fully understand applicable Federal and NYS Motor Vehicle Carrier Safety laws and regulations including, where applicable, those pertaining to the transportation of hazardous materials. If this Application is signed in my official capacity on behalf of a business entity, I further certify that I am duly authorized to make this Application on behalf of such entity.
IMPORTANT: By signing this Application, the Undersigned acknowledges that intentionally making a false statement on this form is a misdemeanor under VTL Section 392, and may result in criminal prosecution, as well as suspension or revocation of the registration of the subject vehicle.
Name of Applicant/Business Entity (please print):
Sign here: X |
|
|
|
Title: |
Date (mm/dd/yyyy): |
/ |
/ |
If signing as agent for a business entity, write your title (CEO, President, Vice-President, Secretary, Treasurer or Comptroller).
Anyone else signing as agent for a business entity must send in a notarized Power of Attorney.