Indiana > Statewide > Department Of Revenue > Motor Carrier
Joint Application For Emergency Or Temporary Authority To Transport Passenger Or Household Goods 711 - Indiana
| Joint Application For Emergency Or Temporary Authority To Transport Passenger Or Household Goods Form. This is a Indiana form and can be used in Motor Carrier Department Of Revenue Statewide . |
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Form 711 State Form 50226 (R4 / 10-12) Indiana ID/USDOT Number _________________________ (To be completed by the department) Joint Application for Emergency or Temporary Authority To Transport Passenger or Household Goods Joint application of the Indiana Department of Revenue for _____________________________ (Emergency Temporary or Temporary) authority pending the sale and transfer of ______________________________. (Certificate or Permit Number) 1. Purchaser Information a. Purchaser's Name (include DBA, if applicable) ________________________________________________________________________________________ b. Street Address ____________________________________________________________________________ c. City, State, Zip Code ________________________________________________________________________ d. Telephone Number ________________ County _____________ Email Address _______________________ e. Principal Place of Business in Indiana (if other than above): ________________________________________________________________________________________ (Street Address) (City) (State) (Zip Code) _______________________________ (County) f. Check One: Partnership _______ Corporation _______ Individual _______ Other _______ g. If purchaser is a partnership, give the name and address of each member thereof; if purchaser is a corporation, give the name, title, and address of each principal officer. Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ Name __________________________ Address _________________________________________________ h. If purchaser is a corporation, LP or LLC, provide the State and the date of incorporation. ________________________________________________________________________________________ (State) (Date of Incorporation) (Total Number of Shares Outstanding) Last year annual report was filed with Indiana Secretary of State ______________________ American LegalNet, Inc. www.FormsWorkFlow.com i. List the name of each shareholder and the number of shares held by each shareholder: Name Number of Shares j. List all other motor carrier companies which hold Indiana Intrastate Authority in which each shareholder has an interest. Provide the Indiana intrastate certificate or permit numbers held by these companies. Motor Carrier Company Certificate or Permit Number k. If currently operating under an Indiana certificate or permit, provide the number: Certificate Number _____________________________ Permit Number _______________________________ 2. Seller Information a. Seller's Name _____________________________________________________________________________ ________________________________________________________________________________________ b. Street Address ____________________________________________________________________________ c. City, State, Zip Code ________________________________________________________________________ d. Telephone Number _____________________________ County _____________________________________ e. Principal Place of Business in Indiana (if other than above): ________________________________________________________________________________________ (Street Address) (City) (State) (Zip Code) _______________________________ (County) f. Check One: Partnership _______ Corporation _______ Individual _______ g. If seller is a partnership, give the name and address of each member thereof; if seller is a corporation, give the name, title, and address of each principal officer: Name _________________________________ Address ___________________________________________ Name _________________________________ Address __________________________________________ Name _________________________________ Address __________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com h. If seller is a corporation, provide the State and the date of incorporation. ________________________________________________________________________________________ (State) (Date of Incorporation) (Total Number of Shares Outstanding) Last year annual report was filed with Indiana Secretary of State: ____________________________________ i. List all Indiana Intrastate Authority certificate or permit numbers which the seller will be retaining. (Attach Copies) ________________________________________________________________________________________ j. Is the seller currently in bankruptcy? Yes No If yes, indicate cause number, date of filing and in what court filed:____________________________________ ________________________________________________________________________________________ k. Has any shareholder, partner or owner of seller ever been a shareholder, partner or owner of a Motor Carrier which has filed bankruptcy? Yes No If yes, complete the following: Name of Shareholder, Partner or Owner Motor Carrier Date of Bankruptcy Petition Cause Number of Bankruptcy Petition Court Filed In Did this motor carrier hold Indiana Intrastate Authority? Yes No If yes, what happened to the certificate or permit as a result of the bankruptcy? ___________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ l. Has the seller performed continuous and adequate service under the certificate or permit now pending sale and transfer? _________________________________________________________________________________ m. In support of this application, please attach a copy of the certificate or permit being transferred including the scope of authority granted by the Department. American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, the joint applicants ask that the Indiana Department of Revenue grant___________________________ (Emergency Temporary or Temporary) authority to purchaser pending the sale and transfer of ____________________ number ________________________ , (Certificate or Permit) authorizing the operation of motor vehicles as a common or contract carrier over the public highways of the State of Indiana upon the route and between the points and serving the cities and towns as authorized by the above numbered certificate or permit. _____________________________________________ (Signature of Attorney or Representative or Purchaser) ___________________________________________ (Signature o
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