Form Mcsb - Kansas Apportioned Registration - Fleet Vehicle Request Form

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Office Use Only
Kansas Apportioned Registration
Received
Date
Fleet Vehicle Request
Entered
Supplement
This completed form may be faxed to 785-296-6548 or mailed to address below; only one vehicle per
form will be accepted.
Mailed Request:
Requestor Name:
Motor Carrier Services Bureau
Requestor Fax:
915 SW Harrison RM. 150
Requestor Email:
Topeka KS 66612
Phone:
IRP Account Number and Fleet:
Name on IRP Account:
Circle Only One:
Lost Plate
Lost Cab
Unit Number
Weight Change
Correction /
Adding
$6.50
Card $3.00
Change
Invoice Amount
Ownership Change
Jurisdiction To Fleet
Plate Number:
Unit Number:
Last 5 of VIN:
Year / Make:
Enter Details of Fleet Vehicle Request:
Jurisdiction
Contract
Jurisdiction
Contract
Jurisdiction
Contract
Miles
Miles
Miles
Jurisdiction
Contract
Jurisdiction
Contract
Jurisdiction
Contract
Miles
Miles
Miles
The undersigned certifies that the information furnished in this application and any supporting documents are true and correct.
_________________
________________________________________________________
_________________________________
Date
Signature
Title
MCSB- Fleet Vehicle Request (11/10)

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