Fillable Printable Form IRP-6 - International Registration Plan Schedule A and C - New York

Form IRP-6 - International Registration Plan Schedule A and C - New York

1. ACCOUNT # _______________________________________ 2. FLEET # __________________________________________

3. REGISTRANT NAME: ____________________________________________________________________________________

4. DBA: __________________________________________________________________________________________________

5. BUSINESS ADDRESS: ____________________________________________________________________________________

CITY: ______________________ STATE: _______ ZIP CODE: ______________ COUNTY: ______________________

6. CONTACT PERSON: ____________________________________________________________________________________

7. PHONE #: ( ) ________________________________

9. EMAIL ADDRESS:________________________________________________________________________________________

10. TAXPAYER IDENTIFICATION # (TIN): ________________________________________________________________________

11. DATE OF BIRTH: ___________________________________ 12.

13. PRIVACY ACT: Check the INFORMATION DISCLOSURE box at the end of this sentence if you do not want your personal

information from this record used for surveys, marketing and solicitations.

14. WY AUTHORITY#:________________________________________________________________________________________

15. REGISTRANT’S DOT: ____________________________________________________________________________________

Have you previously been registered in any jurisdictions?

oYes o No, If yes, jurisdiction ________________________________

Do you lease your vehicle and driver to a motor carrier?

oYes o No

INTERNATIONAL REGISTRATION PLAN

SCHEDULE A & C

IRP-6 (7/15)

TYPE OF APPLICATION REQUESTED

REGISTRANT/CARRIER INFORMATION

FLEET INFORMATION

FLEET TO FLEET TRANSFER INFORMATION

o NEW ACCOUNT

o ADD VEHICLE

o DELETE VEHICLE

o TRANSFER PLATES

o WEIGHT INCREASE

o WEIGHT DECREASE

o RENEWAL

o DUPLICATE CAB CARD

o REPLACEMENT PLATES

o REPLACEMENT STICKER

o FLEET TO FLEET

o ADDRESS CHANGE

o TEMPORARY AUTHORITY

o OTHER____________________

PAR T 1

PAR T 2

16. FLEET TYPE: ____ 17. COMMODITY CLASS: ____ 18. # OF REG MONTHS: ______

19. EFFECTIVE DATE: _______________ 20. EXPIRATION DATE: _____________

21. MAILING ADDRESS: ______________________________________________________________________________________

CITY: ______________________ STATE: _______ ZIP CODE: ______________ COUNTY: ________________________

o Male o Female

(No P.O. Box Number Allowed)

FLEET VEHICLE UNIT #

(OEN) VEHICLE IDENTIFICATION NUMBER FROM FLEET # TO FLEET #

(22) (23) (24) (25)

DELETIONS*

FLEET VEHICLE UNIT #

(OEN)

LICENSE

PLATE NUMBERVEHICLE IDENTIFICATION NUMBER

REPLACEMENT FLEET

VEHICLE UNIT # (OEN)

(26) (28)(27) (29)

PAGE 1 OF 2

* (Send in plates for deletion.)

8. FAX # ( ) ____________________________________

CERTIFICATION: I, the Undersigned, certify under penalty of perjury that all information provided in this Application is true and accurate to the

best of my knowledge, and that the

subject vehicle: is fully equipped, inspected, insured, and will be operated, in compliance with New York State

Vehicle and Traffic Law (VTL); possesses a valid NYS inspection issued within the last twelve (12) months; or, in the alternative, has qualified for

an extension of such inspection (see, DMV form VS-1077) and will be inspected within the next ten (10) days; is covered by a current policy of

insurance or financial security as required by VTL; and if previously “junked”, has been repaired to conform with VTL Sections 375 and 376;

possesses a currently valid NYS registration (if I am using this Application to request issuance of replacement registration documents). I declare that

I fully understand applicable Federal and NYS Motor Vehicle Carrier Safety laws and regulations including, where applicable, those pertaining to the

transportation of hazardous materials. If this Application is signed in my official capacity on behalf of a business entity, I further certify that I am

duly authorized to make this Application on behalf of such entity.

IMPORTANT: By signing this Application, the Undersigned acknowledges that intentionally making a false statement on this form is a misdemeanor

under VTL Section 392, and may result in criminal prosecution, as well as suspension or revocation of the registration of the subject vehicle.

WEIGHT

INFORMATION

Account

# ____________________________________

VEHICLE INFORMATION FOR NEW ACCOUNTS OR ADDITIONS

30. Please list the weight you want on your cab card for all jurisdictions. Canadian jurisdictions will print the weight in kilograms on the

cab card.

31. VEHICLE #1:

AK ____________________

AL ____________________

AR ____________________

AZ ____________________

CA ____________________

CO ____________________

CT ____________________

DC ____________________

DE ____________________

FL ____________________

GA ____________________

IA ____________________

ID ____________________

IL ____________________

IN ____________________

KS ____________________

KY ____________________

LA ____________________

MA ____________________

MD ____________________

ME ____________________

MI ____________________

MN ____________________

MO ____________________

MS ____________________

MT ____________________

NC ____________________

ND ____________________

NE ____________________

NH ____________________

NJ ____________________

NM ____________________

NV ____________________

NY ____________________

OH ____________________

OK ____________________

OR ____________________

PA ____________________

RI ____________________

SC ____________________

SD ____________________

TN ____________________

TX ____________________

UT ____________________

VA ____________________

VT ____________________

WA ____________________

WI ____________________

WV ____________________

WY ____________________

AB ____________________

BC ____________________

MB ____________________

NB ____________________

NL ____________________

NS ____________________

ON ____________________

PE ____________________

QC ____________________

SK ____________________

(Canada)

PAR T 3

PAR T 4

VEHICLE IDENTIFICATION NUMBER

YEAR

FUEL/CYL

WHEELBASE

UNLADEN WT

SEATS

/AXLES

COMBINED

AXLES

COLOR

OWNER NAME

Vehicle Safety responsibility will change

during the year?

SAFETY US DOT #

SAFETY NAME

FLEET VEHICLE # (OEN) MAXIMUM DESIRED WEIGHT

Title:

IRP-6 (7/15)

MAKE VEHICLE TYPE

P) Q)

FACTORY PRICE INS. CO. CODE CURRENT PLATE # CURRENT PLATE CLASS SPECIAL USE

V) W) X) Y) Z)

H) I) J) K)

IF THE REGISTRANT IS NOT THE OWNER, fill in the information below. Proof of ownership, and proof of the

OWNER’S name and date of birth, are required.

Vehicle #1 - Owner’s Name

Address

The person named in number 3 of Part 1 is authorized to register this vehicle in his/her name.

If signing for a corporation, print your full name and title here

Owner’s Authorized

Signature

Name of Applicant/Business Entity (please print):

Sign here:

Date (mm/dd/yyyy): / /

Date:

Apt. No. City State Zip Code

Date of Birth Is the vehicle leased?

o Yes o No

REGISTRATION

AUTHORIZATION

PAGE 2 OF 2

PURCHASE PRICE PURCHASE DATE

T) U)

o Yes o No

TITLE DOC #

TITLE DOC. JUR. SAFETY TAXPAYER ID # (TIN)

L) M) N)

If signing as agent for a business entity, write your title (CEO, President, Vice-President, Secretary, Treasurer or Comptroller).

Anyone else signing as agent for a business entity must send in an original Power of Attorney.

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