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Get Va Dmv Oa144m 2011

FOR-HIRE INTRASTATE OPERATING AUTHORITY CERTIFICATE LICENSE OR PERMIT RENEWAL APPLICATION PURPOSE OA 144M 07/01/2011 Motor carriers use this form to renew their Intrastate Operating Authority Certificate License and/or Permit s and provide business operations information. INSTRUCTIONS Complete all sections. Unsigned applications cannot be processed* SECTION 1 AUTHORITY INFORMATION Check all that apply Broker of Freight Common Carrier-Regular Route Household Goods Sightseeing Broker of Passenger Contract Bus Taxicab Bulk Property Contract Passenger Employee Hauler Non-Emergency Medical Transportation Carrier Nonprofit / Tax Exempt Passenger Carriers Property Carrier Write the number of each certificate license and permit you are applying to renew. Attach a separate page if needed* SECTION 2 BUSINESS INFORMATION BUSINESS NAME For individual applicants give your full legal name FEDERAL TAX IDENTIFICATION NUMBER/SSN TRADE NAME OR DOING BUSINESS AS if different from Business Name BUSINESS STREET ADDRESS do not give P. O. Box CITY STATE ZIP CODE BUSINESS MAILING ADDRESS if different from above PRIMARY CONTACT PERSON NAME TELEPHONE NUMBER FAX NUMBER SECTION 3 OTHER CARRIER INFORMATION Does your business have an IFTA or an IRP account IFTA LICENSE NUMBER NO - Skip to the next section IRP ACCOUNT NUMBER BASE STATE FMCSA MC NUMBER Federal Motor Carrier if applicable 4A. BUSINESS ENTITY TYPE check one CORPORATION YES - enter applicable information DOT NUMBER if applicable PARTNERSHIP Complete Section 4B below INDIVIDUAL OTHER 4B. PARTNERSHIP INFORMATION enter the following information for all partners FULL LEGAL NAME SOCIAL SECURITY NUMBER SECTION 5 CERTIFICATION I affirm that all taxes fees penalties interest and judgements due the Commonwealth of Virginia have been paid or satisfied and that I am in compliance with the Worker s Compensation Act of Title 65. 2 and with the Business Professional and Occupational License Tax requirements. I further certify and affirm that all information presented in this form is true and correct that any documents I have presented to DMV are genuine and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation* I understand that any Virginia Operating Authority permit issued to me can be suspended and revoked if any of the information in the application is found to be untrue or inaccurate. Unsigned applications cannot be processed* SECTION 1 AUTHORITY INFORMATION Check all that apply Broker of Freight Common Carrier-Regular Route Household Goods Sightseeing Broker of Passenger Contract Bus Taxicab Bulk Property Contract Passenger Employee Hauler Non-Emergency Medical Transportation Carrier Nonprofit / Tax Exempt Passenger Carriers Property Carrier Write the number of each certificate license and permit you are applying to renew. Attach a separate page if needed* SECTION 2 BUSINESS INFORMATION BUSINESS NAME For individual applicants give your full legal name FEDERAL TAX IDENTIFICATION NUMBER/SSN TRADE NAME OR DOING BUSINESS AS if different from Business Name BUSINESS STREET ADDRESS do not give P. .

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