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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