Form 707
Indiana ID/USDOT Number _________________________
State Form 50219
(To be completed by the department)
(R4 / 10-12)
Joint Application for Sale and Transfer of Permanent Authority
To Transport Passenger or Household Goods
Joint application for sale and transfer of ___________________ by
(Certifi cate or Permit Number)
the Indiana Department of Revenue.
1. Purchaser Information
a. Purchaser’s Name
________________________________________________________
(include DBA, if applicable)
________________________________________________________________________________________
b. Street Address ____________________________________________________________________________
c. City, State, Zip Code _______________________________________________________________________
d. Telephone Number _____________ County ________________ Email Address ________________________
e. Principal place of business in Indiana (if other than above):
________________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
_______________________________________
(County)
f.
Check One:
Partnership ____ Corporation _____ Individual ____ Other ____
g. If purchaser is a partnership, give the name and address of each member thereof; if purchaser is a corporation,
give the name, title, and address of each principal offi cer.
Name __________________________ Address _________________________________________________
Name __________________________ Address _________________________________________________
Name __________________________ Address _________________________________________________
h. If purchaser is a corporation, LP or LLC, 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 __________________________
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