Form T-140 - Schedule C - International Registration Plan (Irp) Suppplemental Application For Reg
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GEORGIA DEPARTMENT OF REVENUE – PROCESSING CENTER - MOTOR VEHICLE
P
______
_______
Form T-140 (Rev. 4/2013)
AGE
OF
INTERNATIONAL REGISTRATION PLAN (IRP)
SCHEDULE C
SUPPPLEMENTAL APPLICATION FOR REG. YR 2_____
Type, legibly handprint or electronically complete and print this form in blue or black ink.
Please read the instructions on the reverse side of this form.
For additional information and instructions, please read the GA IRP Manual.
(1) Account Number
(2) Fleet Number
Supplement Number
T
O
T
C
A
G
I
W
S
YPE OF
PERATION
YPE OF
HANGE
TTACHMENTS
ENERAL
NFORMATION
EB
ITES
(Check One)
(Check One)
(3) First Name of Registrant or Company Name
Middle Initial
Last Name
FLEET
Add Vehicle(s)
Cab Card for Deleted
ONLY GEORGIA
Department of Revenue
Private Carrier
Add/Delete Vehicle(s)
Vehicles
TITLES WILL BE
https://etax.dor.ga.gov
(4) Business Address in GA. Do not use PO Box. – Include City, State, Zip & GA County Name
Haul for Hire
Fleet to Fleet Transfer
Stamped Copy of Current
ACCEPTED!!
Household Goods
Commodity Class Change
Form 2290
Mailing Address including City, State, Zip & GA County Name
Milk/Fertilizer/Crops
MCS150
PLEASE SUBMIT A
Federal Motor Carrier
Agriculture/Fertilizer
Employment Lease
COPY OF A VALID
Safety Administration
Farm
Notarized Lease
(5) Registrant’s Federal Employer ID # (9-Digits)
USDOT#
GA. DRIVER’S
Forest Products
Agreement
LICENSE
Twin Beam
Notarized Affidavit of
Name of person to contact regarding this application:
Single Beam
Ownership
Insurance Card or Binder
Telephone Number:
FAX Number
Cell Phone Number:
ADDITIONS
(6)
(7)
(8)
(9) Vehicle Identification
(10)
(11)
(12)
(13) Vehicle’s
(14)
(15)
(16) Owner’s Name (Must be Owner
(17) GA Title #
(18) Date
(19)
(20)
(21)
(22)
Fleet#
Weight
Owner’s
Number as shown on title.
No. Of
Empty
Combined
Purchase
Factory
Purchase
Shown on Title)
First
Short
Safety
Carrier’s
Carrier’s
Group
Equip.
Most VINS have 17 digits)
Weight
Gross
Price
List
Date
Operated
Term
Chg.
FEIN#
USDOT#
A
S
#
(Unit) #
Weight
Price
(MM/DD/YY)
in GA
Lease?
Ind.
Vehicle Level
Vehicle Level
X
E
(Y/N)
(Y/N)
L
A
E
T
S
S
DELETIONS
Fleet#
Weight
Apportioned
(23) Deleted
Vehicle
Combined
(24) Reason Vehicle Was Removed
(25) Date
(26) Unit #
Column 20 - Will the control and responsibility for the safety of this vehicle be assigned to a
Group #
License Plate
Equip. #
Identification
Gross
From Fleet
Removed
To Use Plate
different motor carrier during this registration period?
#
Number
Weight
From Fleet
If Applicable
Name of Insurance Company:
Insurance Policy Number:
I do solemnly affirm under criminal penalty of a felony for fraudulent use of a false or fictitious
name or address or for making a material false statement punishable by fines up to $5,000 or by
imprisonment of up to five (5) years, or both that the statements contained herein are true and
accurate. I do certify that the vehicle described is covered by liability insurance as required by the
Georgia Motor Vehicle Accident Reparation Act of 1974, as amended.
Applicant’s Signature & Position or Job Title:
Date:
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