Form 711 Indiana ID/USDOT Number To be completed by Department. State Form 50226 (R3 / 6-06) Joint Application for Emergency or Temporary Authority To Transport Passenger or Household Goods Joint application of the Indiana Department of Revenue for ___________________________ (Emergency Temporary or Temporary) authority pending the sale and transfer of ________________________. (Certificate or Permit Number) 1. Purchaser Information a. Purchaser’s Name (include DBA, if applicable) ___________________________________________________ _____________________________________________________________________________________ b. Street Address______________________________________________________________________ c. City, State, Zip _____________________________________________________________________ d. Telephone ______________________ e. Principal Place of Business in Indiana (if other than above): County ______________________ _____________________________________________________________________________________ (Street Address) (City) (Zip) (State) ______________________ (County) f. Check One: Partnership _____ Corporation _____ Individual _____ Other _____ g. If purchaser is a partnership, give the name and address of each member thereof; if purchaser is a corporation, give the name, title, and address of each principal officer. Name ____________________ Address ___________________________________________________ Name ____________________ Address ___________________________________________________ Name ____________________ Address ___________________________________________________ h. If purchaser 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 _____________________ American LegalNet, Inc. www.FormsWorkflow.com i. List the name of each shareholder and the number of shares held by each shareholder: N ame j. N umber of S hares List all other motor carrier companies which hold Indiana Intrastate Authority in which each shareholder has an interest. Provide the Indiana intrastate certificate or permit numbers held by these companies. Motor C arrier C ompany k. C ertificate or P ermit N o. If currently operating under an Indiana certificate or permit, provide the number: Certificate Number _________________________ Permit Number _________________________ 2. Seller Information a. Seller’s Name ______________________________________________________________________ _____________________________________________________________________________________ b. Street Address______________________________________________________________________ c. City, State, Zip _____________________________________________________________________ d. Telephone _________________________ e. Principal Place of Business in Indiana (if other than above): County _________________________ _____________________________________________________________________________________ (Street Address) (City) (State) (Zip) _________________________ (County) f. Check One: Partnership _____ Corporation _____ Individual _____ g. If seller is a partnership, give the name and address of each member thereof; if seller is a corporation, give the name, title, and address of each principal officer: Name ____________________ Address ___________________________________________________ Name ____________________ Address ___________________________________________________ Name ____________________ Address ___________________________________________________ Form 711 Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com h. If seller is a corporation, 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: _________________________________ i. List all Indiana Intrastate Authority certificate or permit numbers which the seller will be retaining. (Attach Copies) _____________________________________________________________________________________ j. Is the seller currently in bankruptcy? Yes No If yes, indicate cause number, date of filing and in what court filed: ________________________________ _________________________________________________________________________________ k. Has any shareholder, partner or owner of seller ever been a shareholder, partner or owner of a Motor Carrier which has filed bankruptcy? Yes No If yes, complete the following: N ame of Shareholder, Name of Shareholder, Partner, or Ow ner Partner or Owner Motorr Carrier Moto C arrier D ate of Date of B ankruptcy Petition Bankruptcy Petition C au Number Cause se N o. of of B ankruptcy Petition Bankruptcy Petition C ourt Court filed In Filed in Did this motor carrier hold Indiana Intrastate Authority? Yes No If yes, what happened to the certificate or permit as a result of the bankruptcy? ________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ l. Has the seller performed continuous and adequate service under the certificate or permit now pending sale and transfer? ___________________________________________________________________ m. In support of this application, please attach a copy of the certificate or permit being transferred including the scope of authority granted by the Department. Form 711 Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com WHEREFORE, the joint applicants ask that the Indiana Department of Revenue grant ____________________ (Emergency Temporary or Temporary) authority to purchaser pending the sale and transfer of ____________________ number __________________ , (Certificate or Permit) authorizing the operation of motor vehicles as a common or contract carrier over the public highways of the State of Indiana upon the route and between the points and serving the cities and towns as authorized by the above numbered certificate or permit. _________________________________________ _________________________________________ (Signature of Attorney or Representative or Purchaser) (Signature of Purchaser) _________________________________________ _________________________________________ (Print Name of Attorney or Representative) (Print Name of Purchaser) _________________________________________ (Address) _________________________________________ (Telephone Number) STATE OF ______________ ) ) SS: COUNTY OF ____________ ) Before me the undersigned, a Notary Public for _______________ County, State of Indiana, personally appeared ________________, and he being first duly sworn by me upon his oath, says that the facts alleged in the forgoing instrument are true. Signed and sealed this _____ day of ____________________, 20 _____. ______________________________________________ (Signature) Notary Public ______________________________________________ (Printed Name) County of Residence: ___________________________ My Commission Expires: _____________________________________ ____________________________________ ______________________________________________ (Signature of Attorney or Representative of Seller) (Signature of Seller) ____________________________________ ______________________________________________ (Print Name of Attorney or Representative) (Print Name of Seller) ____________________________________ (Address) ____________________________________ (Telephone Number) STATE OF ______________ ) ) SS: COUNTY OF ____________ ) Before me the undersigned, a Notary Public for _______________ County, State of Indiana, personally appeared ________________, and he being first duly sworn by me upon his oath, says that the facts alleged in the forgoing instrument are true. Signed and sealed this _____ day of ____________________, 20 _____. ____________________________________________________ (Signature) Notary Public ____________________________________________________ (Printed Name) County of Residence: ___________________________ Form 711 My Commission Expires: _____________________________________ Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com Instructions for Joint Application of Emergency Temporary or Temporary Authority Pending the Sale and Transfer of Certificate or Permit Please read these instructions carefully before completing the application. The application for emergency temporary or temporary authority pending the sale and transfer of a certificate or permit 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 company, 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 contract, or a copy of the contract, or a copy of the 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; 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). 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 711 Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com