Application For Emergency Or Temporary Authority To Transport Passenger Or Household Goods {703}

State Form 50216 (R5 / 3-16) Form 703 Indiana ID/USDOT Number __________________ (To be completed by the department) Application for Emergency or Temporary Authority To Transport Passenger or Household Goods Application for ___________________ (Common or Contract) _________________________ authority prior to (Emergency Temporary or Temporary) permanent authorization by the Indiana Department of Revenue. 1. Applicant Carrier's Name (include DBA, if applicable) _________________________________________________ ___________________________________________________________________________________________ 2. Street Address _______________________________________________________________________________ 3. City, State, Zip Code ___________________________________________________________________________ 4. Telephone Number ________________ County ________________ Email Address ________________________ 5. Principal Place of Business in Indiana (if other than above): ___________________________________________________________________________________________ (Street Address) (City) (State) (Zip Code) __________________________________ (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) Indicate the last year your annual report was filed with the Indiana Secretary of State ________________________ 9. List the name of each shareholder and the number of shares held by each shareholder: Name Number of Shares 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 Carrier Company Certificate or Permit No. Shareholder Number of Shares 11. Is applicant currently in bankruptcy? Has applicant ever filed for bankruptcy? Yes Yes No 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 If yes, complete the following: Motor Carrier Date of Bankruptcy Petition Cause Number of Bankruptcy Petition Court Filed In Name of Shareholder, Partner or Owner Did any motor carrier listed above hold Indiana Intrastate Authority? Yes 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? ___________________________________________________________________________________________ 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: _____________________ (Certificate or Permit) Date Filed: _______________________ (Common or Contract) 14. I hereby apply for a __________________________ to operate motor vehicles as a _________________________ 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): _________________________________________________________________________ _________________________________________________________________________________