Free 37028.pdf - Indiana

Please send all applications to:

APPLICATION FOR TRANSPORT OPERATOR PLATES
State Form 37028 (R5 / 1-09)

Approved by State Board of Accounts, 2009 INDIANA BUREAU OR MOTOR VEHICLES

Reset Form

Indiana Bureau of Motor Vehicles 309 West South Street Winchester, IN 47394 Telephone: 765-584-7038 Fax number: 765-584-7190

SECTION 1. APPLICANT INFORMATION If an out of state entity, please provide address and telephone number for the office located in Indiana.
Official name of entity Entity Address (number and street) City Type of Business (select one): County State ZIP code Business telephone number ( ) Federal Identification Number

IN
Sole Proprietorship Partnership Corporation

Unincorporated Association

SECTION 2. PARTNER OR OFFICER CONTACT INFORMATION List information for executive officer or, if no executive officer exists, list the general partners in a partnership. Attach an additional sheet of paper if necessary. NAME TITLE ADDRESS TELEPHONE NUMBER

SECTION 3. TRANSPORT INFORMATION
Transport operator's principal type of business If a Regulated Carrier, please indicate your FMCSA Interstate Operating Authority Number (Motor Carrier, Freight Forwarder, or Motor Broker Number) List the states in which you intend to operate Brief description of each style or type of motor vehicle transported (e.g. cars, trucks, motor homes, boats) (attach additional sheet if necessary) Basis of Financial Responsibility (certificate of insurance must be included with application) Insurance policy number (if applicable) Date of expiration (month, day, year)

SECTION 4. INVOICE A. For initial requests, check the applicable box beside (A) or (B) in the below section. If you are ordering additional sets of plates, check the box beside (C) and indicate the number of additional sets of plates you are requesting. B. For established accounts with the Bureau of Motor Vehicles, check the box beside (C) and indicate the number of additional sets of plates you are requesting. Check all FEE that apply A. Initial Set (2 Plates) Only: $139.25 B. Initial 2 Sets (4 Plates): C. Additional Plate Sets: TOTAL AMOUNT DUE $ 158.25 $34.25 / each set Quantity of sets $ $ $ $

SECTION 5. PAYMENT INFORMATION Application must be accompanied by a check or money order made payable to the Bureau of Motor Vehicles or credit card information and signature.
Type of payment (select one)

Check / Money order
Credit card number

MasterCard

Visa
Expiration date (month, day, year)

SECTION 6. AFFIRMATION AND SIGNATURE The authorized representative swears or affirms under the penalty of perjury that the information provided in this application is true and correct. By signing, the representative also authorizes the Bureau of Motor Vehicles to charge the above listed credit card.
Signature of authorized entity representative Printed name of authorized entity representative Date (month, day, year)