Form 711 - Joint Application For Emergency Or Temporary Authority - To Transport Passenger Or Household Goods Page 3

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h. If seller is a corporation, provide the State and the date of incorporation.
________________________________________________________________________________________
(State)
(Date of Incorporation)
(Total Number of Shares Outstanding)
Last year annual report was fi led with Indiana Secretary of State: ____________________________________
i.
List all Indiana Intrastate Authority certifi cate or permit numbers which the seller will be retaining. (Attach Copies)
________________________________________________________________________________________
□
□
j.
Is the seller currently in bankruptcy?
Yes
No
If yes, indicate cause number, date of fi ling and in what court fi led: ____________________________________
________________________________________________________________________________________
k. Has any shareholder, partner or owner of seller ever been a shareholder, partner or owner of a Motor Carrier
□
□
which has fi led bankruptcy?
Yes
No
If yes, complete the following:
Name of
Motor Carrier
Date of
Cause Number
Court Filed In
Shareholder,
Bankruptcy
of Bankruptcy
Partner or Owner
Petition
Petition
□
□
Did this motor carrier hold Indiana Intrastate Authority?
Yes
No
If yes, what happened to the cer-
tifi cate or permit as a result of the bankruptcy? ___________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
l.
Has the seller performed continuous and adequate service under the certifi cate or permit now pending sale and
transfer? _________________________________________________________________________________
m. In support of this application, please attach a copy of the certifi cate or permit being transferred including the scope
of authority granted by the Department.

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