WHEREFORE, the joint applicants ask that the Indiana Department of Revenue approve the sale and transfer of
____________________ number ____________________ and issue a ______________________ to the purchaser
(Certifi cate or Permit)
(Certifi cate or Permit)
authorizing the operation of motor vehicles as a ____________________ carrier over the public highways of the State of
(Common or Contract)
Indiana upon the route and between the points and serving the cities and towns as authorized by the above numbered
__________________________.
(Certifi cate or Permit)
_____________________________________________
___________________________________________
(Signature of Attorney or Representative or Purchaser)
(Signature of Purchaser)
_____________________________________________
___________________________________________
(Print Name of Attorney or Representative)
(Print Name of Purchaser)
_____________________________________________
(Address)
_____________________________________________
(Telephone Number)
STATE OF _____________
)
) SS:
COUNTY OF ____________ )
Before me the undersigned, a Notary Public for ____________________ County, State of ______________, personally
appeared ________________, and he being fi rst duly sworn by me upon his oath, says that the facts alleged in the
foregoing instrument are true. Signed and sealed this ______ day of _______________, 20 _____.
____________________________________
(Signature) Notary Public
____________________________________
(Printed Name)
County of Residence: ___________________________ My Commission Expires: __________________
_____________________________________________
___________________________________________
(Signature of Attorney)
(Signature of Seller)
_____________________________________________
___________________________________________
(Print Name of Attorney)
(Print Name of Seller)
_____________________________________________
(Address)
_____________________________________________
(Telephone Number)
_____________________________________________
(Email Address)
STATE OF _____________
)
) SS:
COUNTY OF ____________ )
Before me the undersigned, a Notary Public for ____________________ County, State of ______________, personally
appeared ________________, and he being fi rst duly sworn by me upon his oath, says that the facts alleged in the
foregoing instrument are true. Signed and sealed this ______ day of _______________, 20 _____.
____________________________________
(Signature) Notary Public
____________________________________
(Printed Name)
County of Residence: ___________________________ My Commission Expires: __________________