Form Ipr-6 - International Registration Plan, Schedule A & C Page 2
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1
2WEIGHT
PART 3
Account
# ____________________________________
INFORMATION
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)
PART 4
VEHICLE INFORMATION FOR NEW ACCOUNTS OR ADDITIONS
31. VEHICLE #1:
D)
A)
B)
C)
E)
F)
VEHICLE IDENTIFICATION NUMBER
FUEL/CYL
WHEELBASE
YEAR
MAKE
VEHICLE TYPE
G)
H)
I)
J)
K)
UNLADEN WT
COMBINED
SEATS
COLOR
OWNER NAME
/AXLES
AXLES
L)
TITLE DOC #
M)
TITLE DOC. JUR.
N)
SAFETY TAXPAYER ID # (TIN)
O)
SAFETY US DOT #
P)
Vehicle Safety responsibility will change
Q)
SAFETY NAME
during the year?
o Yes
o No
R)
T)
PURCHASE PRICE
U)
PURCHASE DATE
FLEET VEHICLE # (OEN)
S)
MAXIMUM DESIRED WEIGHT
V)
W)
X)
Y)
Z)
FACTORY PRICE
INS. CO. CODE
CURRENT PLATE #
CURRENT PLATE CLASS
SPECIAL USE
IF THE REGISTRANT IS NOT THE OWNER, fill in the information below. Proof of ownership, and proof of the
REGISTRATION
OWNER’S name and date of birth, are required.
AUTHORIZATION
Vehicle #1 - Owner’s Name
Date of Birth
Is the vehicle leased?
o
o
Yes
No
Address
Apt. No.
City
State
Zip Code
The person named in number 3 of Part 1 is authorized to register this vehicle in his/her name.
Owner’s Authorized
-
Date:
Signature
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
: is fully equipped, inspected, insured, and will be operated, in compliance with New York State
subject vehicle
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:
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 an original Power of Attorney.
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IRP-6 (7/15)
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