Form 76-111-08-1-1-000 (Rev. 8/08)
INTERNATIONAL REGISTRATION PLAN APPLICATION STATE OF MISSISSIPPI SCHEDULE A
Please Print or Type
Page ________of ______
Account Name Business Physical Address City County State Zip
DBA Name
Mailing Address
License Year
Account Number
Fleet Number
FEIN SSN US DOT #
Person to contact regarding application: County State Zip City State Phone Number
City
TYPE OF OWNERSHIP Sole Owner ADDITIONS 2. 1.
Owner's Unit Number Y E A R
Partnership 4.
Vehicle Identification Number
Corporation 5. 6.
T Y P E
A X L E S
Has Vehicle(s) ever been registered in another state Yes No 10. 11. 12.
Purchase Date
3.
Make
7. 8.
S E A T S
9.
Unladen (Empty) Weight
13.
Name of Lessor
14.
Title Number
F U E L
Combined Cost of Gross Weight Vehicle
** FED ID / TIN US DOT # Previous License No. Vehicle Level Y/ N Vehicle Level
15.
16.
17.
18.
19.
Delivery Date
** If the carrier responsible for safety is expected to change during the year, the indicator should be set to Y.
DELETIONS
1. Owner's Unit Number 2. Y E A R 3. Make 4. Vehicle Identification Number 5. Combined Gross Weight 6. Apport. License Number 7. Reason Removed
If the carrier responsible for saftey is not expected to change during the year, the indicator should be set to N. CODE
Type TR - Tractor TK - Single Truck FT - Trailer BS - Bus PU - Pickup SD - Limousine Fuel D - Diesel G - Gas P - Propane
CHECK ONE
PC-Private Carrier HH-Haul for Hire
(Hauling Others' Goods)
Total Number of Units Added Total Number of Units Deleted
RC-Rental Carrier HC-Household Goods Carrier
FOR OFFICE USE ONLY
Pre-payment
The undersigned, under oath, swears under penalty of perjury that the information furnished on this application and the attached schedules is true and correct.
By Title
Trade-in Tag
This
Day of
SIGNATURE REQUIRED
SCHEDULE B
Account Name
County
INTERNATIONAL REGISTRATION PLAN APPLICATION STATE OF MISSISSIPPI
Business Street Address (Where Records are Maintained) State Zip License Year Account Number City
Page ________of ______
Fleet Number
A. Mark "X" in box for each state where you are filing for proportional registration. B. Mark "X" if estimated miles. C. List Mileage for each jurisdiction in which this fleet traveled July 1, _______ through June 30, ________ A. STATE B. C. MILES AL (Alabama) AZ (Arizona) AR (Arkansas) CA (California) CO (Colorado) CT (Connecticut) DE (Delaware) DC (District of Columbia) FL (Florida) GA (Georgia) ID (Idaho) IL (Ilinois) IN (Indiana) IA (Iowa) KS (Kansas) KY (Kentucky) LA (Louisiana) ME (Maine) MD (Maryland) MA (Massachusetts) MI (Michigan) A. STATE MN (Minnesota) MS (Mississippi) MO (Missouri) MT (Montana) NE (Nebraska) NV (Nevada) NH (New Hampshire) NJ (New Jersey) NM (New Mexico) NY (New York) NC (North Carolina) ND (North Dakota) OH (Ohio) OK (Oklahoma) OR (Oregon) PA (Pennsylvania) RI (Rhode Island) SC (South Carolina) SD (South Dakota) TN (Tennessee) TX (Texas) B. C. MILES A. STATE UT (Utah) VT (Vermont) VA (Virginia) WA (Washington) WV (West Virginia) WI (Wisconsin) WY (Wyoming) AB (Alberta) BC (British Columbia) MB (Manitobia) NB (New Brunswick) NF (Newfoundland) NS (Nova Scotia) ON (Ontario) PE (Prince Edward Island) QC (Quebec) SK (Saskatchewan) B. C. MILES
TOTAL MILES
Explain in detail the scope of operation for any estimated mileage: Schedule G
(FOR OFFICE USE ONLY)