Form Inirp-A - Application For The International Registration Plan - Schedule A
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1
2Form INIRP-A
State of Indiana
State Form 4947 (R2 / 2/11)
Application for the International Registration Plan
SCHEDULE A
Please refer to the back for instructions.
9. Mailing Address:
16. IRP Account /Fleet Number:
17. License Year:
1. Legal Name:
18. Staggered Month:
□
□
2. Business Entity Type:
10. County:
11. City:
19. New Account:
20. Taxpayer Identifi cation Number:
□
□
□
□
Incorporation
□
Sole-Proprietorship
Partnership
Yes
No
Nonprofi t
Government Owned
3. Federal ID Number (or Social Security Number if Sole-Proprietor):
12. State:
13. Zip Code:
21. Account Contact Person’s Name:
4. Indiana Business Street Address:
14. Indiana Business Telephone Number:
22. Contact Telephone Number:
5. County:
6. City:
7. State: 8: Zip Code:
15. E-mail Address:
23. Account Fax Number:
Please list the entire names and Social Security Number of owners, partners or coporate offi cers. (Attach a separate sheet if necessary.)
Last, First and Middle Initial:
Social Security Number:
Last, First and Middle Initial:
Social Security Number:
Below, please indicate the appropriate weight where proportional registration is sought in a jurisdiction.
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
MX
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PE
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
U
Y
M
Vehicle
T
Axles
Motor
Motor
Is Lease
F
Unladen
Declared
Declared
Purchase
Factory
Purchase
Owner
Carrier
n
e
a
Identifi cation
y
or
Carrier
less than
u
Weight
Gross
Combined
Price
Price
Date
FEIN/SSN
i
a
k
Number
p
Seats
U.S. DOT
30 days?
e
Weight
Gross
Responsible
t
r
e
e
Number
Yes/No
l
Weight
for Safety
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