International Registration Plan Supplemental Application Schedule C

              Name of Registrant (Print or Type)
Business Address (Must Indicate Address in Base Jurisdiction
City State Zip
FEIN or SSN or TIN
Mailing Street Address
City State Zip
USDOT Number Page of License Year License Month Fleet Number Account Number
Person to Contact Regarding Application Phone Number Jurisdictional Use
International Registration Plan Weight Schedule (List the combined gross weight, in pounds, for which the vehicles are to be registered)
AL
KY
NY
WV
AZ
LA
NC
WI
AR
ME
ND
WY
CA
MD
OH
AB
CO
MA
OR
BC
CT
MI
PA
MB
DE
MN
RI
NB
DC
MS
SC
NF
FL
MO
SD
NS
GA
MT
TN
ON
ID
NE
TX
PE
IL
NV
UT
SK
IN
NH
VT
PQ
IA
NJ
VA
KS
NM
WA
1
CURRENT
LICENSE
PLATE
2
EQUIPMENT
NUMBER
3
Y
E
A
R
4
MAKE
5
VEHICLE
IDENTIFICATION
NUMBER
6
T
Y
P
E
7
A
X
L
E
S
S
E
A
T
S
8
F
E
U
L
9
DECLARED
COMBINED
GROSS
WEIGHT
10
UNLADEN
WEIGHT
12
TITLE
NUMBER
11
NAME
OF OWNER
13
DATE OF
PURCHASE
14 A
FACTORY
PRICE
14 B
PURCHASE
PRICE
TIN assigned to this USDOT _____________________Is this expected to change during the year? ____Yes ____No _
Vehicle Type:
TT - Truck Tractor
TR - Tractor
TK - Truck (Single)
RT - Road Tractor
ST - Semi Trailer
FT - Full Trailer
BS - Bus
CG - Converter Gear
Fuel:
D - Diesel
G - Gas
P - Propane
Type of Carrier:
( ) Common Exempt Commodities
( ) Rental
( ) Private
( ) Haul for Hire
( ) Household goods
or Carnival
Number of Power Units _______
Number of Trailers _______
The undersigned, under oath, swears under penalty of perjury that the
information furnished in this application and supporting documents is
true and correct and also, that he/she will comply with the mandatory
records retention as outlined in OCC Rule 165:30-19-8.
Signature Title Date
Enter the USDOT of the carrier responsible for safety, of the above VIN, if different than the Registrant's _____________
Supplement No.
Prorate
Tag
Number
Deleted
Unit
Number Year Make
Vehicle
Identification
Number
License
Weight
Title
Number
Added
Number Reason Removed
Operating Authority Number
Vehicle(s) To Be Deleted From Fleet
Enter the USDOT of the carrier responsible for safety, of the above VIN, if different than the Registrant's _____________ Is this expected to change during the year? ____Yes ____No TIN assigned to this USDOT ______________________
Enter the USDOT of the carrier responsible for safety, of the above VIN, if different than the Registrant's _____________ Is this expected to change during the year? ____Yes ____No TIN assigned to this USDOT ______________________
Enter the USDOT of the carrier responsible for safety, of the above VIN, if different than the Registrant's _____________ Is this expected to change during the year? ____Yes ____No TIN assigned to this USDOT ______________________
Unit
Total Combined Axles:
OKLAHOMA
Registrant's Phone Number
Revised 5-2012 International Registration Plan
Supplemental Application
Schedule C
Please Read Before Completing Applications
All applications must be completed and are subject to being denied until all appropriate information is included.
The following is general information to aid in the filing of uour application for appeortioned registration.
Use Schedules "A" and "B" when filing renewals, amended applications addinf jurisdictions or establishing a new account.
Use Schedules "C"when adding and/or deleting equipment.
Please note: When filing an amended application to add jurisdiction(s), those jurisdiction(s) must be added to all vehicles in the fleet
Schedule "B" is your Fleet Distance Report for the current year registration. You must list all miles traveled by your vehicles registered in that fleet during the
previous reporting period of July 1 through June 30.
Example: If your renewal is between January and September For the 2008 you will report distance operated by your fleet from July 1, 2006
through June 30, 2007. Between October and December you will report distance operated by your fleet from July 1, 2007 through June 30, 2008.
Estimated Milage: If you qualify to estimate, you must use one of the following methods:
You may provide a full statement of the proposed method of operation. Use schedule G to indicate routes, origins, destinations, 1. and distance.
or
2. If you are leased to a carier, you may provide a copy of the miles reported by the carrier with which you are leased.
or
3. You may use the distance listed on the Oklahoma Corporation Commission estimated distance chart.
For each vehicle on which apportioned registration is sought, the folliwing documentation, when applicable, is needed:
1. Copy of prior registration
2. Proof of ownership
3. Proof of payment of Heavy Vehicle Use Tax (Federal Form 2290 Schedule one)
4. Proof of insurance
a. Oklahoma Security Verification form
or
b. ICC or OCC Authority Number
5. Copy of lease to authorized carrier.
By signing the front of this application, you have indicated that you hace read the following and will comply.
In accordance with the International Registration Plan Inc. (IRP) and Oklahoma statutes, it is mandatory that you maintain mileage records supporting the distance
Traveled in each jurisdiction. These records are to be maintained for a period of five (5) years including your current registration year and shall be produced upon
request by the Oklahoma Corporation Commission Transportation Division.