Form Irp-6 - International Registration Plan Schedule A&c
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1
2INTERNATIONAL REGISTRATION PLAN
IRP-6 (7/15)
SCHEDULE A & C
PART 1
TYPE OF APPLICATION REQUESTED
o
o
o
o
ADDRESS CHANGE
NEW ACCOUNT
WEIGHT INCREASE
DUPLICATE CAB CARD
o
o
o
o
TEMPORARY AUTHORITY
ADD VEHICLE
WEIGHT DECREASE
REPLACEMENT PLATES
o
o
o
o
OTHER____________________
DELETE VEHICLE
RENEWAL
REPLACEMENT STICKER
o
o
TRANSFER PLATES
FLEET TO FLEET
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:
____________________________________________________________________________________
8. FAX # (
) ____________________________________
7. PHONE #: (
) ________________________________
9. EMAIL ADDRESS:________________________________________________________________________________________
10. TAXPAYER IDENTIFICATION # (TIN): ________________________________________________________________________
o
o
11. DATE OF BIRTH: ___________________________________ 12.
Male
Female
13. PRIVACY ACT: Check the INFORMATION DISCLOSURE box at the end of this sentence if you do not want your personal
o
information from this record used for surveys, marketing and solicitations.
14. WY AUTHORITY#:________________________________________________________________________________________
15. REGISTRANT’S DOT: ____________________________________________________________________________________
o
o
Have you previously been registered in any jurisdictions?
________________________________
Yes
No, If yes, jurisdiction
o
o
Do you lease your vehicle and driver to a motor carrier?
Yes
No
FLEET INFORMATION
16. FLEET TYPE: ____
17. COMMODITY CLASS: ____
18. # OF REG MONTHS: ______
19. EFFECTIVE DATE: _______________
20. EXPIRATION DATE: _____________
21. MAILING ADDRESS: ______________________________________________________________________________________
(No P.O. Box Number Allowed)
CITY: ______________________
STATE: _______
ZIP CODE: ______________
COUNTY: ________________________
PART 2
FLEET TO FLEET TRANSFER INFORMATION
(22)
(23)
(24)
(25)
FLEET VEHICLE UNIT #
(OEN)
VEHICLE IDENTIFICATION NUMBER
FROM FLEET #
TO FLEET #
*
DELETIONS
(26)
(27)
(28)
(29)
FLEET VEHICLE UNIT #
LICENSE
REPLACEMENT FLEET
(OEN)
VEHICLE IDENTIFICATION NUMBER
PLATE NUMBER
VEHICLE UNIT # (OEN)
*
(Send in plates for deletion.)
PAGE 1 OF 2
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