Form 711 - Joint Application For Emergency Or Temporary Authority - To Transport Passenger Or Household Goods Page 2

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i.
List the name of each shareholder and the number of shares held by each shareholder:
Name
Number of Shares
j.
List all other motor carrier companies which hold Indiana Intrastate Authority in which each shareholder has an
interest. Provide the Indiana intrastate certifi cate or permit numbers held by these companies.
Motor Carrier Company
Certifi cate or Permit Number
k. If currently operating under an Indiana certifi cate or permit, provide the number:
Certifi cate Number _____________________________ Permit Number _______________________________
2. Seller Information
a. Seller’s Name _____________________________________________________________________________
________________________________________________________________________________________
b. Street Address ____________________________________________________________________________
c. City, State, Zip Code ________________________________________________________________________
d. Telephone Number _____________________________ County _____________________________________
e. Principal Place of Business in Indiana (if other than above):
________________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
_______________________________
(County)
f.
Check One:
Partnership _______ Corporation _______ Individual _______
g. If seller is a partnership, give the name and address of each member thereof; if seller is a corporation, give the
name, title, and address of each principal offi cer:
Name _________________________________ Address ___________________________________________
Name _________________________________ Address __________________________________________
Name _________________________________ Address __________________________________________

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