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Fillable Printable Power of Attorney Template - Oregon

Fillable Printable Power of Attorney Template - Oregon

Power of Attorney Template - Oregon

Power of Attorney Template - Oregon

POWER OF ATTORNEY
INSTRUCTIONS : 1) Provide ALL information and check the applicable boxes. 2) Form must be signed by the Owner, a Partner in a Partnership or
Limited Liability Partnership; a Corporate Officer, a Manager or Member of a Limited Liability Company (LLC) and the Power of Attorney. 3) The motor
carrier business location address is required.
MCTD ACCOUNT NUMBER
MOTOR CARRIER NAME
ATTORNEY-IN-FACT BUSINESS NAME
LOCATION ADDRESS MAILING ADDRESS
CITY CITY
SIGNATURE OF MOTOR CARRIER BINDING THIS AGREEMENT SIGNATURE OF ATTORNEY-IN-FACT BINDING THIS AGREEMENT
PRINTED NAME OF SIGNATURE ABOVE PRINTED NAME OF SIGNATURE ABOVE
TITLE
Owner Partner of Partnership or LLP
Corporate Officer
Manager or Member/LLC
TITLE OF ATTORNEY-IN-FACT
DATE TELEPHONE NUMBER DATE TELEPHONE NUMBER
This Power of Attorney will be in effect beginning and continues until canceled.
The Motor Carrier listed above does hereby designate and appoint the Pow er of Attorney listed above to act as Attorney-in-Fact for
the following purposes (check appli c able provisions):
a)
To initiate closure of the account for the Motor Carrier.
b)
To obtain, complete, and sub mit a pplication for Oregon Weight Receipt and Tax Identifiers (Receipts), to obtain
temporary tax credentials and/or Over-Dime nsional/Weight permits. To have the ability to cancel receipts.
c)
To prepare, sign and submit documents and payments which may be necessary for filing highw ay use tax reports and
Road Use Assessment Fees.
d)
Sign highway use tax bonds.
e)
To obtain, complete, and sub mi t a pplication and fees for International Registration Plan (IRP) and International Fuels Tax
Agreement (IFTA) License and decals. To obtain, complete, and submit application and fees for Registration of vehicles
operating in Oregon only. To have the ab ility to cancel IFTA and Ore gon based Registration.
f)
Change motor carrier address and/or telephone number. All corresponde nce, plates and Receipts may be mailed to:
ADDRESS CITY
g)
Specify Other:
This Power of Attorney cancels all other Powe r of Attorney agreements for this MCTD Account.
TO CANCEL THIS POWER OF ATTORNEY, COMPLETE THE INFORMATION BELOW AND SEND A COPY TO ODOT/MCTD.
THIS POWER OF ATTORNEY IS CANCELED ON: DATE
SIGNATURE PRINTED NAME OF SIGNATURE
TITLE
Owner Partner (Partnership or LLP) Corporate Officer LLC Manager or Member Power of Attorney
ZIP STATE
ZIP STATE ZIP STATE
FORM 735-9654 (3-15)
h)
Request an Oregon Trucking Online Personal Identi fication Number (PIN).
OREGON DEPARTMENT OF TRANSPORTATION
MOTOR CARRIER TRANSPORTATION DIVISION
3930 FAIRVIEW INDUSTRIAL DRIVE SE
SALEM OR 97302-1166
PH (503) 378-6699
FAX (503) 378-6880
If using Trucking Online or other we b services, all transactions identified above, whether checked or unchecked, are automatically
approved. This
Power of Attorney grants permission for the Orego n Department of Transportation to release accou nt, ve hicle,
and payment info rmation to the Attorney-in-Fact. This Power of Attorney does not relieve the motor carrier from the responsibility
of filing timely, accurate reports and applications.
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