Form Oa 144m - For-Hire Intrastate Operating Authority Certificate, License, Or Permit Renewal Application

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FOR-HIRE INTRASTATE OPERATING AUTHORITY
OA 144M (01/01/2018)
CERTIFICATE, LICENSE, OR PERMIT
RENEWAL APPLICATION
PURPOSE:
Motor carriers use this form to renew their Intrastate Operating Authority Certificate, License and/or Permit(s) and provide
business operations information.
INSTRUCTIONS: Complete all sections. Unsigned applications cannot be processed. For-hire certificates/licenses can be denied, revoked or
suspended due to certain circumstances. Refer to
for specific denial/revocation/suspension reasons.
SECTION 1 — AUTHORITY INFORMATION
Check all that apply:
Broker of Passenger
Contract Passenger
Sightseeing
Employee Hauler
Taxicab
Nonprofit / Tax Exempt Passenger Carrier
Common Carrier-Irregular Route
Household Goods
Non-Emergency Medical Transportation Carrier
Common Carrier-Regular Route
Property Carrier
Write the number of each certificate, license, and permit you are applying to renew. Attach a separate page if needed.
SECTION 2 — BUSINESS INFORMATION
BUSINESS NAME (For individual applicants, give your full legal name)
FEDERAL TAX IDENTIFICATION NUMBER/SSN
TRADE NAME OR DOING BUSINESS AS (if different from Business Name)
BUSINESS STREET ADDRESS (do not give P.O. Box)
CITY
STATE
ZIP CODE
BUSINESS MAILING ADDRESS (if different from above)
CITY
STATE
ZIP CODE
PRIMARY CONTACT PERSON NAME
TELEPHONE NUMBER
FAX NUMBER
(
)
(
)
PRIMARY CONTACT PERSON TITLE
PRIMARY CONTACT PERSON EMAIL ADDRESS
SECTION 3 — OTHER CARRIER INFORMATION
IRP ACCOUNT NUMBER (if applicable)
BASE STATE
IFTA LICENSE NUMBER (if applicable)
BASE STATE
FMCSA MC NUMBER (Federal Motor Carrier) (if applicable)
DOT NUMBER (if applicable)
SECTION 4 — BUSINESS ENTITY INFORMATION
4A. BUSINESS ENTITY TYPE (check one)
CORPORATION
PARTNERSHIP (Complete Section 4B below)
INDIVIDUAL
OTHER
4B. PARTNERSHIP INFORMATION (enter the following information for all partners)
FULL LEGAL NAME
SOCIAL SECURITY NUMBER
SECTION 5 — CERTIFICATION
I affirm that all taxes, fees, penalties, interest, and judgements due the Commonwealth of Virginia have been paid or satisfied and that I am in compliance with
the Worker's Compensation Act of Title 65.2 and with the Business, Professional, and Occupational License Tax requirements. I further certify and affirm that all
information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all
supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false
statement or representation on this form is a criminal violation. I understand that any Virginia Operating Authority certificate, license or permit issued to me can
be suspended and revoked if any of the information in the application is found to be untrue or inaccurate.
APPLICANT OR AUTHORIZED REPRESENTATIVE NAME
APPLICANT OR AUTHORIZED REPRESENTATIVE TITLE
APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)

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