South Dakota Combined Irp/ifta Application Page 2
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2IRP CARRIER SECTION
A USDOT Number is required when applying for IRP Registration
USDOT:
IRP Contact Name:
Phone Number:
Cell Number:
Fax Number:
CARRIER TYPE (must select one):
Private
For Hire
If household goods or rental, please identify:
Briefly describe your type of operation:
If you are a new IRP applicant, you are required to maintain a place of business in your home jurisdiction comprised of a telephone and
actual structure where all records can be maintained, and if necessary, made available for audit.
REPORTING SERVICE SECTION: IRP
(Power of Attorney must accompany application)
Reporting Service Name:
Employer Identification Number:
Social Security Number:
PHYSICAL ADDRESS:
Street
City
State
Zip Code
MAILING ADDRESS:
Street
City
State
Zip Code
Phone Number:
Cell Number:
Fax Number:
E-mail Address;
IFTA CARRIER SECTION
A USDOT Number is required when applying for IFTA Registration
USDOT:
IFTA Contact Name:
Phone Number:
Cell Number:
Fax Number:
FUEL TYPE:
Diesel
Gasoline
LPG
CNG
Gasohol
Other
Do you have bulk storage?
Yes
No
You require
set(s) of decals at $2.50 per set. There is a $10.00 fee for renewal, new license, or reinstatement. Your total remittance is
$
. Payment must be included with application. Applications remitted without payment cannot be processed.
REPORTING SERVICE SECTION: IFTA
(Power of Attorney must accompany application)
Reporting Service Name:
Employer Identification Number:
Social Security Number:
PHYSICAL ADDRESS:
Street
City
State
Zip Code
MAILING ADDRESS:
Street
City
State
Zip Code
Phone Number:
Cell Number:
Fax Number:
E-mail Address:
Under penalty of perjury I hereby certify that the statements contained herein are true and correct.
Signature
Title
Date
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Parent category: Financial