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International Registration Plan Florida Application

In order for the international registration plan to be fully effective and official in the State of Florida, the following form has to be completed and submitted.

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NAME OF REGISTRANT:	 	       	PLEASE TYPE OR PRINT WITH INK	 	 TYPE OF OPERATION    (Select one choice):	 	
FLORIDA BUSINESS ADDRESS (NO NOT USE P. O. BOX):	 	        	INTERNATIONAL REGISTRATION PLAN	 	
FLORIDA APPLICATION	 	 	EXEMPT COMMODITY  CARRIER	 
 	HOUSEHOLD GOODS  CARRIER	 	
CITY  
        COUNTY
 
        STATE
 
FLORIDA   ZIP CODE
 
       	SCHEDULE  A  	 	FOR HIRE CARRIER	 	 PRIVATE CARRIER
 (OWNS GOODS 
BEING  TRANSPORTED ) 	
MAILING 	ADDRESS	 (REGISTRANT’S	):  See Below for Service Provider Information  	   	       	
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES	 	BUREAU OF COMMERCIAL VEHICLE AND DRIVER SERVICES	 	  TYPE OF APPLICATION    (C heck  	 as applies):	 	
CITY	 	       	
COUNTY	 	      	STATE	 	      	ZIP CODE	 	      	2900 Apalachee Parkway, MS	-62 	Tallahassee, Florida 32399- 6552	 	 	ORIGINAL	 
 	TRANSFER 	
PERSON TO CONTACT 	REGARDING APPLICATION:	 	       	
Telephone (850) 617	-3711	 	http://www.flhsmv.gov	 	 	RENEWAL	 
 	INCREASE WEIGHT 	
EMAIL ADDRESS 	(CVISN ACCOUNTS MUST HAVE 	AN EMAIL ADDRESS	): 	       	
 	
 	ADD FLEET	 
 	FLEET TO FLEET TRANSFER  	
IF THE ABOVE ADDRESSES OR TELEPHONE NUMBER ARE DIFFERENT FROM	 	WHAT WAS  ON YOUR PREVIOUS APPLICATION,  PLEASE CHECK  	 and include   	                                    	3 PROOFS	 OF 	ESTABLISHED PLACE OF BUSINESS	 with 85900 IRP Application	: 	 	ADD VEHICLE	 	 	CORRECTION (	TYPE OF CORRECTION ): 	       	 	 
 	
REGISTRANT’S  TELEPHONE NUMBER :  	      	 	U.S. DOT NUMBER:         	 	Registrant’s  FEI # 	(THIS # IS REQUIRED TO REFERENCE YOUR  IFTA ACCOUNT)	:          	 	
IRP ACCOUNT NUMBER:   	      	  FLEET NUMBER:
  	      	 	LICENSE YEAR:  	      	 	
COLORADO LOW MILEAGE	 – Check (	√  ) any vehicle traveling in Colorado that will	 travel	 	  less than 10,000 miles	 total in all jurisdictions in the column	 under CO	LO. LOW 	MILES	. 		  	  VEHICLE INFORMATION  		  	 	
 	
TRANSACTION TYPES :	 	A – ADD VEHICLE           C – CORRECTION  D – DELETE VEHICLE   O 	– ORIGINAL  R 	– RENEWAL  	 	VEHICLE TYPES:	 	TT - TRUCK TRACTOR     TK 	– TRUCK (SINGLE)	 	
TR 	– TRACTOR       	       	   BS 	– BUS	 	FUEL TYPES:	 	D – DIESEL    G – GAS   P -  PROPANE	 	 
 	
TRANS-
ACTION  
TYPE   OWNER’S
 
UNIT  
NUMBER  	YEAR  M
 
A  
K  
E   VEHICLE
 
IDENTIFICATION  
NUMBER   T
 
Y  
P  
E  	# of 
AXLES 
POWER  UNIT   # of 
AXLES 
TRAILER  	BUS 
SEATS  	F 
U  
E  
L  	  
CO LO . 
L OW  
M ILES 	C O  
L  
O  
R 	
GROSS OR  
COMBINED  
GROSS  
W EIGHT    
EMPTY  
W EIGHT    
DATE OF  
PURCHASE  
(M / D / Y)    
OW NER’S  
PURCHASE  
PRICE   FLORIDA
 
TITLE 
NUMBER  	CARRIER RESPONSIBLE FOR VEHICLE SAFETY	 	U.S. DOT 	NUMBER 
ASSIGNED 
TO VEHICLE	 	
TAX PAYER  
IDENTIFICATION NUMBER  
(EIN, SSN)  
ASSIGNED TO VEHICLE  WILL THE DESIGNATED 
CARRIER  RESPONSIBLIE 
FOR SAFETY CHANGE 
DURING THE  YEAR?  	
                       	      	        	       	      	      	      	 	       	                                                                  YES          NO             	
                       	      	        	       	      	      	      	 	       	                                                                  YES          NO             	
                       	      	        	      	      	      	       	 	      	                                                                  YES          NO             	
                       	      	        	      	      	      	       	 	      	                                                                  YES          NO             	
                       	      	        	      	      	      	       	 	      	                                                                  YES          NO             	
                       	      	        	       	      	      	      	 	       	                                                                  YES          NO             	
                       	      	        	       	      	      	      	 	       	                                                                  YES          NO             	
                       	      	        	    
     	      	      	      	   
   
     	                                                                  YES          NO             	
PLEASE  BE SURE	 	
YOU PRINTED YOUR NAME,  
SIGNED THE APPLICATION,  
AND ENCLOSED THE  
FOLLOWING REQUIRED   		 	
DOCUMENTATION, AS NECESSARY.	 	
 3 PROOFS OF ESTABLISHED PLACE OF BUSINESS 	(new 	account or address change only	) 	 PROOF OF PAYMENT OF HEAVY VEHICLE USE TAX         (IRS FORM 2290 in Registrant’s or Title owner’s name)   PROOF OF BODILY INJURY AND PROPERTY DAMAGE LIABILITY INSURANCE WITH PIP          (referred to as Combined Single Limits –  CSL) with the DHSMV as Certificate Holder   PROOF OF OWNERSHIP   OUT OF STATE TITLES MUST HAVE COPY OF CLEAR TITLE FRONT AND BACK OR A COPY OF        THE RECEIPT FOR THE ELECTRONIC TITLE, VIN VERIFICATION FORM AND A LETTER FROM   
      THE LIEN -HOLDER OR LEAS E AGREEMENT                                    
 COPY OF LEASE, IF APPLICABLE    	
NAME OF CARRIER SERVICE PROVIDER (If Applicable) 	 ( USE  FOR MAILING ADDRESS)  	  Check 	 this  BOX  	 	          
ADDRESS:
         
CITY:   COUNTY:  STATE:  ZIP CODE: 
                               
TELEPHONE NUMBER:          	
HSMV 85900 (Rev . 10 /2014 )

SCHEDULE B – MILEAGE  INFORMATION AND  WEIGHT 	
UNITS LISTED WILL BE AUTHORIZED TO  	
OPERATE AT THE WEIGHTS LISTED BELOW  	
ENTER ACTUAL MILES 	TRAVELED BY FLEET 	
VEHICLES FOR THE PERIOD  	 	
JULY 1,       THROUGH JUNE 30,        	 	
Will you be operating intrastate in the state of Wyoming? 	 
 	
YES         NO            (Please 	 one ) 	
JURISDICTION  	ACTUAL	 	
MILES	 	GVW  JURISDICTION 	ACTUAL	 	
MILES	 	GVW  JURISDICTION 	ACTUAL	 	
MILES	 	GVW 	
FL – FLORIDA                   MI – MICHIGAN                   TX –  TEXAS                 
AL  –  ALABAMA                 	MN  –  MINNESOTA  	                UT –  UTAH                 	
AK  - ALASKA                  MO – MISSOURI                   VA – VIRGINIA                  
AR  – ARKANSAS                  MS –  MISSISSIPPI                   VT –  VERMONT                  
AZ  – ARIZONA                   MT –  MONTANA                   WA –  WASHINGTON                  
CA  – CALIFORNIA                 	NC  –  NORTH CAROLINA  	                WI – WISCONSIN                  	
CO  –  COLORADO                   ND – NORTH DAKOTA                  	WV  –  WEST VIRGINIA 	                	
CT  –  CONNECTICUT                   NE – NEBRASKA                  WY –  WYOMING                  
DC  – DIST. OF COLUMBIA                  NH – NEW HAMPSHIRE                  AB – ALBERTA                 
DE  – DELAWARE                  NJ –  NEW JERSEY                  BC – BRITISH COLUMBIA                  
GA  –  GEORGIA                   NM –  NEW MEXICO                   MB – MANITOBA                 
IA  –  IOWA                   NV – NEVADA                  MX – MEXICO                  
ID  –  IDAHO                   NY – NEW YORK                  NB – NEW BRUNSWICK                 
IL  –  ILLINOIS                   OH –  OHIO                   NL –  NEWFOUND/LABRA.                 
IN  –  INDIANA                   OK –  OKLAHOMA                  NS – NOVA SCOTIA                  
KS  – KANSAS                  OR –  OREGON                   NT –  NW TERRITORY                  
KY  – KENTUCKY                  PA – PENNSYLVANIA                   ON – ONTARIO                  
LA  –  LOUISIANA                   RI – RHODE ISLAND                  PE – PRINCE ED. ISL.                  
MA  –  MASSACHUSETTS  	                SC – SOUTH CAROLINA                   QC –  QUEBE C                 	
MD  – MARYLAND                  SD – SOUTH DAKOTA                   SK – SASKATCHEWAN                  
ME  -  MAINE                   TN – TENNESSEE                  YT -  YUKON                 
Application for apportioned registration is a declaration of knowledge that Florida has adopted the federal motor  carrier safety regulations and federal hazardous material regulations and the 
registrant is familiar with the applicable requirements.  I certify that the information furnished in 
this application and the attachments is true and correct and that I have read and understand the 
records retention requirements for the International Registration Plan and will comply with them.  
 PRINTED	 NAME	: 	      	    SIGNATURE __________________________________________________________________________________________  TITLE	: 	      	 DATE	: 	      	 THIS APPLICATION MUST BE SIGNED BY THE REGISTRANT UNLESS REGISTRANT SUBMITS A   
HSMV 96440 POWER OF ATTORNEY DESIGNATING THE PERSON SIGNING AS AN AUTHORIZED AGENT.	 	
PLEASE DO NOT SEND MONEY  WITH THIS APPLICATION.  A BILL WILL BE CALCULATED  	AND MAILED TO YOU. 	 
 
 	
APPLICATIONS ARE WORKED ON FIRST RECEIVED BASIS	 	
 
TOTAL THE ACTUAL MILES LISTED ABOVE AND ENTER HERE     	       	
 
TO BE COMPLETED FOR ORIGINAL  IRP APPLICATIONS ONLY:   Does this fleet and/or vehicles have any history of prior IRP registration In another jurisdiction?	 	YES	        	 NO         	 	 What 	jurisdiction?	 	      	 Does this fleet and/or vehicles have any history of prior Florida IRP	 Registration?	 	YES	        	 NO         	 	 Has your registration ever been suspended or 	revoked?	 	YES	         NO          	 
 	HSMV 85900 (Rev. 10/2014 )
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