Irp Form T-139 - Georgia Irp Mileage Schedule A

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Georgia IRP Vehicle Schedule A (Form T-138)
IRP Form T-138 (Rev. 4/2013)
Page 1 of 4
Section 1 Please read all instructions on this form before completing.
Click here
to view additional information. This form must be typed, electronically completed & printed or legibly hand printed & signed.
(1) New Account?
(2) 5-Digit GA IRP Account#
(3) 3-Digit GA Fleet#
(4) 3-Digit GA Supplement#
(5) Registrant’s US DOT#
(6) Registrant’s TIN or SSN:
No
Yes - If yes, attach
Schedule G, Form T-239
(7) Registrant’s/Carrier’s Full Legal Name & Business Address in Georgia (include city, state & zip code). If the Registrant/Carrier is an individual, record first name, middle name, last name & suffix. A post
office box number is not acceptable.
(7a) Georgia County Name:
(8) Registrant’s/Carrier’s Mailing Address (include city, state & zip) if different from the address shown in #7 above. A post office box is acceptable
(9) Registrant’s/Carrier’s Business Phone # +
(9a) Registrant’s/Carrier’s Cell Phone # + Area
(9b) Registrant’s/Carrier’s Fax # + Area Code:
(9c) Registrant’s/Carrier’s E-Mail Address:
Area Code:
Code:
(10) Contact Person’s Name:
(10a) Contact Person’s Phone # + Area Code:
(10b) Contact Person’s FAX # + Area Code:
(10c) Contact Person’s Internet E-Mail Address:
(11) Wyoming Intrastate?
Yes
No
(13) Reason For Application:
(12) Type of Operation – Check the box that applies to your operation:
Private Carrier:
For Hire Carrier:
Renewal
All Commodities
All Commodities
New Fleet
Truck-Tractor – Fertilizer/Milk/Crops
Household Goods
Add State(s)
Farm Vehicle – Farm Products/Farm Equip.
Bus – Record Number of Seats: _________
Increase Weight
Straight Truck – Agriculture/Fertilizer
Forest Products – Check one box below:
Twin Beam Trailer
Single Pole Trailer
SECTION 2
(1) Weight Group Number: __________________ If you are a first-time Georgia IRP registrant, leave this field blank and a number will be assigned.
(2) Record the maximum gross vehicle weight that each vehicle in this fleet will travel in the following jurisdictions:
Jurisdictions
Jurisdictions
Jurisdictions
Jurisdictions
Jurisdictions
(AB) Alberta
(IA) Iowa
(MO) Missouri
(NV) Nevada
(TN) Tennessee
(AK) Alaska
(ID) Idaho
(MS) Mississippi
(NY) New York
(TX) Texas
(AL) Alabama
(IL) Illinois
(MT) Montana
(OH) Ohio
(UT) Utah
(AR) Arkansas
(IN) Indiana
(MX) Mexico
(OK) Oklahoma
(VA) Virginia
(AZ) Arizona
(KS) Kansas
(NB) New Brunswick
(ON) Ontario
(VT) Vermont
(BC) British Columbia
(KY) Kentucky
(NC) North Carolina
(OR) Oregon
(WA) Washington
(CA) California
(LA) Louisiana
(ND) North Dakota
(PA) Pennsylvania
(WV) West Virginia
(CO) Colorado
(MA) Massachusetts
(NE) Nebraska
(PE) Prince Edward Island
(WI) Wisconsin
(CT) Connecticut
(MB) Manitoba
(NF) Newfoundland
(QC) Quebec
(WY) Wyoming
(DE) Delaware
(MD) Maryland
(NH) New Hampshire
(RI) Rhode Island
(YT) Yukon Territory
(DC) District of Columbia
(ME) Maine
(NJ) New Jersey
(SC) South Carolina
(FL) Florida
(MI) Michigan
(NM) New Mexico
(SD) South Dakota
(GA) Georgia
(MN) Minnesota
(NT) Northwest Territory
(SK) Saskatchewan

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