Form Oa 141 S - Motor Carrier Certificate Or License Application Supplement Information Release Authorization
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1MOTOR CARRIER
OA 141 S (06/04/2015)
CERTIFICATE OR LICENSE APPLICATION SUPPLEMENT
INFORMATION RELEASE AUTHORIZATION
Purpose:
This form must be completed to authorize the release of information to any agent or representative of the Virginia Department of Motor Vehicles
for the purpose of evaluating a holder of or applicant for, a Motor Carrier Certificate or License.
Instructions:
Submit an Information Release Authorization for the owner (if sole proprietor), for each partner (if partnership or limited liability partnership), or
officer/member/manager (if corporation or limited liability company). For applicants for a Motor Carrier Certificate or License, every person listed
as a Business Official on the application must complete and submit an Information Release Authorization. If additional releases are needed,
DMV will accept photocopies of this form.
RELEASE AUTHORIZATION INFORMATION
BUSINESS NAME (MUST match the business name provided on your Motor Carrier Certificate or License application)
TRADE NAME OR DOING BUSINESS AS (if different from Business Name)
I/we the undersigned, hereby authorize and consent, to the release of my criminal history information to any agent or representative of the
Virginia Department of Motor Vehicles (DMV). This authorization and consent is given as a result of an application to DMV's Motor Carrier
Services to either obtain, or renew an operating authority certificate or license.
BUSINESS OFFICIAL INFORMATION
BUSINESS OFFICIAL'S FULL NAME (last, first, middle initial)
BUSINESS OFFICIAL'S TITLE
DATE OF BIRTH (mm/dd/yyyy)
SOCIAL SECURITY NUMBER (Do not list company FEIN)
DRIVER LICENSE NUMBER
ISSUING STATE
SEX
RACE
CITY OR COUNTY OF BIRTH
STATE OR COUNTRY OF BIRTH
TELEPHONE NUMBER
(
)
PERSONAL RESIDENTIAL ADDRESS
CITY
STATE
ZIP CODE
BUSINESS OFFICIAL SIGNATURE
DATE SIGNED (mm/dd/yyyy)
NOTARIZATION (must be completed by notary public)
NOTARY PUBLIC SEAL
Commonwealth of Virginia, city or county of _____________________________________ subscribed and
sworn before me on this _________________ day of __________________________________________
(MONTH)
(YEAR)
by___________________________________________________ in the city or county and state aforesaid.
REGISTRATION NUMBER (6 digits)
MY COMMISSION EXPIRES (mm/dd/yyyy)
NOTARY PUBLIC NAME
NOTARY PUBLIC SIGNATURE
BUSINESS OFFICIAL INFORMATION
BUSINESS OFFICIAL'S FULL NAME (last, first, middle initial)
BUSINESS OFFICIAL'S TITLE
DATE OF BIRTH (mm/dd/yyyy)
SOCIAL SECURITY NUMBER (Do not list company FEIN)
DRIVER LICENSE NUMBER
ISSUING STATE
SEX
RACE
CITY OR COUNTY OF BIRTH
STATE OR COUNTRY OF BIRTH
TELEPHONE NUMBER
(
)
PERSONAL RESIDENTIAL ADDRESS
CITY
STATE
ZIP CODE
BUSINESS OFFICIAL SIGNATURE
DATE SIGNED (mm/dd/yyyy)
NOTARIZATION (must be completed by notary public)
NOTARY PUBLIC SEAL
Commonwealth of Virginia, city or county of _____________________________________ subscribed and
sworn before me on this _________________ day of __________________________________________
(MONTH)
(YEAR)
by___________________________________________________ in the city or county and state aforesaid.
REGISTRATION NUMBER (6 digits)
MY COMMISSION EXPIRES (mm/dd/yyyy)
NOTARY PUBLIC NAME
NOTARY PUBLIC SIGNATURE
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