Free WI IRP Application Schedule B Amendment - Wisconsin

WI IRP APPLICATION SCHEDULE B AMENDMENT
MV2912 2/2004

Clear Form

FAX to 608-267-6886
Account No Fleet No Start Date Registrant Name

Wisconsin Department of Transportation PO Box 7955 Madison, WI 53707-7955 Telephone: 608-266-9900 E-mail: [email protected]

WI
U.S. DOT No Contact Person - Regarding Application Contact Person - Area Code-Telephone Number Area Code-FAX Number

Type Name Change Add State(s) or Canadian Province(s)

Mark (X) in the box for added jurisdiction(s).
X JURISDICTION AB- Alberta MILEAGE EST X JURISDICTION MA- Massachusetts MB- Manitoba MD- Maryland ME- Maine MI- Michigan MN- Minnesota MO- Missouri MS- Mississippi MT- Montana NB- New Brunswick NC- North Carolina ND- North Dakota NE- Nebraska NF- Newfoundland NH- New Hampshire NJ- New Jersey NM- New Mexico NS- Nova Scotia NV- Nevada NY- New York MILEAGE EST X JURISDICTION OH- Ohio OK- Oklahoma ON- Ontario OR- Oregon PA- Pennsylvania PE- Prince Edward Is. QC- Quebec RI- Rhode Island SC- South Carolina SD- South Dakota SK- Saskatchewan TN- Tennessee TX- Texas UT- Utah VA- Virginia VT- Vermont WA- Washington WI- Wisconsin WV- West Virginia WY- Wyoming TOTAL FLEET MILES MILEAGE EST

Operation Type Private For Hire Authority Number Household Goods Rental Company Owner/Operator

Business Type Sole Owner Partnership Corporation

AL- Alabama AR- Arkansas AZ- Arizona BC- British Columbia CA- California CO- Colorado CT- Connecticut DC- District Columbia DE- Delaware FL- Florida GA- Georgia IA- Iowa ID- Idaho IL- Illinois IN- Indiana KS- Kansas KY- Kentucky

Area Below For DOT Use Only

Application Billed
(Processor ID)

LA- Louisiana