Form T-138a - Georgia Irp Application - Vehicle Schedule A Continuation (Legal Size)

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Form T -138A(Legal Size) Rev. 4/2013

Georgia IRP Application

Vehicle Schedule A Continuation (Legal Size)

https://etax.dor.ga.gov

Page 1 of 2

SECTION 1

Registrant’s TIN # or Social Security #

(1)

New Account?

Yes

(2)

5-Digit Georgia IRP Account #

(3)

3-Digit Georgia Fleet #

(4)

3-Digit Georgia Supplement #

(5)

Registrant’s US DOT #

(6)

If y es, attach Schedule G (Form

T -239).

(7)

Registrant’s /Carrier’s Full L ega l Name(s) and Business Address in Georgia

SECTION 2

Additional vehicles not listed on Schedule A (Form T-138)

(1)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(2)

Empt y

Combi ned

Short

Carrier’s

Safety

Unit/

Ve hicle’s

Factor y

Owner(s)’

Vehicle

on Number (VIN)

Weight of

Gross

Term

FEIN #

USDOT #

Change

Georgia Title #

Equip. #

Purchase

List Price

Legal Name(s)

Vehicle

Weight

Axles

Lease

Y/N

Price

Y/N

Vehicle Level

Seats

Column - (13)

Will the control and safety of this vehicle be assigned to a different Motor Carrier during the registration year?

SECTI ON 3

Imp ortant: Do not send money with this application. You will be billed later. Application I R P registration can be made by mail or in-person.

(1) Under penalty of perjury, I hereby certify that I am the Registrant/Carrier or I am authorized to sign for the above name Registrant/Carrier. I further certify that the information shown on this form and all attachments is complete and correct.

(

Signature

)

(

Printed Name

)

(

Position or Job Title

)

(

Date

)