Form Mcs-50 - Schedule D For First-Year Applicants printable pdf download

MOTOR CARRIER SERVICE BUREAU

SCHEDULE “D” FOR FIRST-YEAR APPLICANTS

Name___________________________________ SS#/FEIN#__________________

Address_________________________________ Phone Number_________________

_______________________________________ Account Number________________

1. Indicate by check mark ( √ ) how your vehicle(s) were registered in the prior year:

A.____Kansas base plate;

Name and Plate No.________________________

B.____Kansas IRP plate;

Name and Plate No.________________________

C.____Foreign base plate;

Name and Plate No.________________________

Jurisdiction

*If foreign base plate,indicate

of issuance______________________

D.____Other_______________________________________________________

2. Have you previously been denied registration?

YES_____

NO_____

3. In the past have you had IRP registration in Kansas?

YES_____

NO_____

If yes,

please indicate the name and account number of previous file___________

_________________________________________________________________

4. Has your registration ever been suspended or revoked? YES____

NO_____

5. Do you hold any type of operating authority?

YES____

NO_____

Describe briefly:____________________________________________________

6. Are your vehicle(s) presently leased to any individual company?

YES___

NO___

If yes,

list name and address of the lessee_______________________________

_________________________________________________________________

Have you ever been audited by Kansas,

or any other IRP jurisdiction?

YES____

NO_____

Have your vehicle(s) been previously registered under any other name?

YES____

NO_____

If yes,

list each name and address_____________________________________

________________________________________________________________

Has any Licensing Service, Remittance Agency, Trucking Service Agency,

Consultants, or other individual(s) assisted you in the preparation of your IRP

application?

YES____

NO_____

List the individual(s), or Agent’s name and address________________________

________________________________________________________________

10. How did you determine the jurisdictions you have chosen to apportion with?______

_________________________________________________________________

I (We) hereby affirm that the information set forth herein is true and correct.

___________________________________

____________________________

Authorized Signature

Date

Authorized Signature

Date

___________________________________

____________________________

Title

MCS – 50www

Form Mcs-50 - Schedule D For First-Year Applicants

Related Articles

Related forms

Related Categories