Form 711
Indiana ID/USDOT Number _________________________
State Form 50226
(To be completed by the department)
(R4 / 10-12)
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 ______________________________.
(Certifi cate or Permit Number)
1. Purchaser Information
a. Purchaser’s Name (include DBA, if applicable)
________________________________________________________________________________________
b. Street Address ____________________________________________________________________________
c. City, State, Zip Code ________________________________________________________________________
d. Telephone Number ________________ County _____________ Email Address _______________________
e. Principal Place of Business in Indiana (if other than above):
________________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
_______________________________
(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 offi cer.
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 fi led with Indiana Secretary of State ______________________