Form 703 - Application For Emergency Or Temporary Authority - To Transport Passenger Or Household Goods Page 3
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513. If an application for permanent authority has previously been fi led for the same operations described in question 14
below, give the docket number of the application and the date the application was fi led:
Docket Number: _____________________
Date Filed: _______________________
14. I hereby apply for a __________________________ to operate motor vehicles as a _________________________
(Certifi cate or Permit)
(Common or Contract)
carrier of _________________________ in intrastate commerce.
(Passenger or Household Goods)
___________________________________________________________________________________________
(Type(s) of Household Goods or Passengers to be Transported)
___________________________________________________________________________________________
___________________________________________________________________________________________
(Territorial Scope in which Household Goods or Passengers will be Transported)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Restrictions: _________________________________________________________________________________
___________________________________________________________________________________________
15. If this application is for a permit, complete the following regarding contracting shipper:
Name
__________________________________________________________________________________
Address
__________________________________________________________________________________
__________________________________________________________________________________
Type(s) of Household Goods or Passengers to be Transported: _________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Name
__________________________________________________________________________________
Address
__________________________________________________________________________________
__________________________________________________________________________________
Type(s) of Household Goods or Passengers to be Transported: _________________________________________
□
□
16. Is applicant now operating under an Indiana intrastate certifi cate(s) and/or permit?
Yes
No
If yes, give number(s): _________________________________________________________________________
___________________________________________________________________________________________
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