Indiana ID/USDOT Number__________________________ To be completed by Department. Form 703 State Form 50216 (R3 / 6-06) Application for Emergency or Temporary Authority To Transport Passenger or Household Goods Application for __________________ authority prior to (Emergency Temporary or Temporary) (Common or Contract) permanent authorization by the Indiana Department of Revenue. 1. Applicant Carrier’s Name (include DBA, if applicable) ____________________________________________ _____________________________________________________________________________________ 2. Street Address _________________________________________________________________________ 3. City, State, Zip _________________________________________________________________________ 4. Telephone ______________________ County ______________________ 5. Principal Place of Business in Indiana (if other than above): _____________________________________________________________________________________ (Street Address) (City) (Zip) (State) ______________________ (County) 6. Check One: Partnership _____ Corporation _____ Individual _____ Other _____ 7. If applicant is a partnership, give the name and address of each member thereof; if applicant is a corporation, give the name, title, and address of each principal officer: Name ____________________ Address ___________________________________________________ Name ____________________ Address ___________________________________________________ Name ____________________ Address ___________________________________________________ 8. If applicant is a corporation, LP or LLC, provide the State and the date of incorporation: _____________________________________________________________________________________ (State) (Date of Incorporation) (Total Number of Shares Outstanding) Last year annual report was filed with Indiana Secretary of State _____________________ 9. List the name of each shareholder and the number of shares held by each shareholder: N ame N umber of S hares American LegalNet, Inc. www.FormsWorkflow.com 10. List all other motor carrier companies which hold Indiana Intrastate Authority in which each shareholder has an interest; indicate the number of shares held by that shareholder: Motor C arrier C ompany C ertificate or Permit N o. 11. Is applicant currently in bankruptcy? Has applicant ever filed for bankruptcy? Yes Shareholder N umber of Shares No Yes No If yes, indicate cause number, date of filing and in what court filed: _______________________________ _____________________________________________________________________________________ 12. Has any shareholder, partner or owner of applicant ever been a shareholder, partner or owner of a motor carrier which has filed bankruptcy? Yes No N ame of Shareholder, Name of Shareholder, Partner, orr Owner r Partner o Ow ne If yes, complete the following: Motorr Carrierr Moto C arrie D ate of f Date o B ankruptcyPetitionn Bankruptcy Petitio C au Number of Cause se N o. of B ankruptcy Petitionn Bankruptcy Petitio Did any motor carrier listed above hold Indiana Intrastate Authority? Yes C our Court t filed in Filed In No If yes, indicate certificate or permit number: ______________________________ What was the disposition of the certificate or permit as a result of the bankruptcy? ________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Did that motor carrier list the State of Indiana as a creditor? Yes No If yes, state what debt was owed and whether the debt was discharged or paid pursuant to a reorganization? _____________________________________________________________________________________ Form 703 Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 13. If an application for permanent authority has previously been filed for the same operations described in question 14 below, give the docket number of the application and the date the application was filed: Docket Number: ____________________ Date Filed: ____________________ 14. I hereby apply for a _________________________ to operate motor vehicles as a ____________________ (Certificate or Permit) (Common or Contract) carrier of _________________________ in intrastate commerce. (Passenger or Household Goods) _____________________________________________________________________________________________ (Type(s) of Household Goods or Passengers to be Transported) _____________________________________________________________________________________________ _____________________________________________________________________________________________ (Territorial Scope in which Household Goods or Passengers will be Transported) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Restrictions: 15. If this application is for a permit, complete the following regarding contracting shipper: Name: Address: Type(s) of Household Goods or Passengers to be Transported: ___________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Name: Address: Type(s) of Household Goods or Passengers to be Transported: ___________________________________________ 16. Is applicant now operating under an Indiana intrastate certificate(s) and/or permit? Yes No If yes, give number(s): Form 703 Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com 17. In support of this application, applicant submits the following exhibits, attached hereto and made part hereof. ExhibitA - A statement describing applicant’s financial status, including a brief statement of assets and liabilities as of the date of application, and a copy of applicant’s most recent balance sheet and income statement. Exhibit B - A certificate from the Secretary of State of Indiana showing applicant is registered to do business in Indiana (if the applicant is a non-resident corporation); or A certificate of existence from the Secretary of State of Indiana (if the applicant is an Indiana corporation). Exhibit C - If applicant is currently in bankruptcy, a copy of the bankruptcy petition. Exhibit D - Copies of all Indiana intrastate certificates or permits reflecting authority granted there in. WHEREFORE, applicant asks the Indiana Department of Revenue to authorize applicant to operate motor vehicles over the public highways of the state as set forth herein. DATED THIS _______________ DAY OF _______________, 20 _____. _______________________________________________________ (Applicant’s Signature) _______________________________________________________ (Print Applicant’s Name) _______________________________________________________ (Title) _________________________________________________ (Signature of Attorney or Representative of Applicant) _________________________________________________ (Print Name of Attorney or Representative) _________________________________________________ (Address) _________________________________________________ _________________________________________________ (Telephone) STATE OF ______________ ) ) SS: COUNTY OF ____________ ) Before me the undersigned, a Notary Public for _______________ County, State of ______________, personally appeared ____________________, and he being first duly sworn by me upon his oath, says that the facts alleged in the foregoing instrument are true. Signed and sealed this __________ day of _______________, 20 _____. ____________________________________________________ (Signature) Notary Public ____________________________________________________ (Printed Name) County of Residence: _______________ Form 703 My Commission Expires: _______________ Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com Form 703 Instructions Instructions for Application of Common or Contract Emergency Temporary Authority or Temporary Authority Please read these instructions carefully before completing the application. Definitions: Common Carrier Contract Carrier Certificate Permit - A person holding itself out to the general public to provide motor vehicle transportation for compensation. A person, providing motor vehicle transportation for compensation under continuing contract(s) for named shipper(s). The document issued by the Department to a Common Carrier. The document issued by the Department to a Contract Carrier. The application for emergency temporary or temporary authority must be typewritten or legible. The original and one copy of the application must be filed. Each line of the application must be completed. If a line is not applicable to you or your operation, you should enter “N/A” in the space provided for the answer. 45 IAC 16-1.5-3 Any person may appear and represent his or her own interest before the commission. The interest of another person or entity shall be represented only by an attorney authorized to practice before the commission, pursuant to this section. In order for the application to be processed by the Department, you must include the following with your application: 1. A filing fee of $100.00; make checks payable to the Indiana Department of Revenue; 2. Two copies of a tariff (if you are seeking authority to operate as a common carrier); or Two copies of a schedule of minimum rates and a copy of each proposed signed contract, or a copy of the signed contract with rates attached (if you are seeking authority to operate as a contract carrier); 3. Proof of insurance as required by I.C. 8-2.1-22-46 and 45 IAC 16-1-2. Your insurance company must file a Form E with the Indiana Department of Revenue which indicates the amount of coverage. 4. A certificate from the Secretary of State of Indiana showing that you are registered to do business in Indiana (if your company is a non-resident corporation); or A certificate of existence from the Secretary of State of Indiana (if your company is an Indiana corporation); and 5. Affidavits from members of the shipping public which establish that an emergency and/or immediate need exists for the proposed service. 6. A statement describing applicant’s financial status, including a brief statement of assets and liabilities as of the date of application, and a copy of applicant’s most recent balance sheet and income statement. If you have any questions regarding this application, please contact the Department at: Indiana Department of Revenue Motor Carrier Services Insurance and Safety Unit 5252 Decatur Blvd., Ste. R Indianapolis, Indiana 46241 or call (317) 615-7295 Form 703 Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com