Form 703
Indiana ID/USDOT Number __________________
(To be completed by the department)
State Form 50216
(R4 / 10-12)
Application for Emergency or Temporary Authority
To Transport Passenger or Household Goods
Application for ___________________
_________________________ authority prior to
(Common or Contract)
(Emergency Temporary or Temporary)
permanent authorization by the Indiana Department of Revenue.
1. Applicant Carrier’s Name (include DBA, if applicable) _________________________________________________
___________________________________________________________________________________________
2. Street Address _______________________________________________________________________________
3. City, State, Zip Code ___________________________________________________________________________
4. Telephone Number ________________ County ________________ Email Address ________________________
5. Principal Place of Business in Indiana (if other than above):
___________________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
__________________________________
(County)
6. Check One: Partnership ______ Corporation ______ Individual ______ Other ______
7. If applicant is a partnership, give the name and address of each member thereof; if applicant is a corporation, give the
name, title, and address of each principal offi cer:
Name _______________________ Address _______________________________________________________
Name _______________________ Address _______________________________________________________
Name _______________________ Address _______________________________________________________
8. If applicant is a corporation, LP or LLC, provide the State and the date of incorporation:
___________________________________________________________________________________
(State)
(Date of Incorporation)
(Total Number of Shares Outstanding)
Indicate the last year your annual report was fi led with the Indiana Secretary of State ________________________
9. List the name of each shareholder and the number of shares held by each shareholder:
Name
Number of Shares