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Home My WebLink AboutHO201300061 Legacy Document 2013-10-23OA 150 (10/10/2013) 191 OPERATING AUTHORITY www.dmvN&W.com CERTIFICATE OR LICENSE APPLICATION Virginia Department of Motor Vehicles Post Office Boz 27412 Richmond, Virginia 2320D•0001 Purpose: Use this form to apply for or change existing authority to operate as a carrier within Virginia for the authority types identified below. For information on how to obtain For -Hire Intrastate Operating Authority for types of for -hire services not identified below, visit www.dmvNow.com. Instructions: To ensure accurate and timely processing of your application, read and follow all steps outlined in the Operating Authority Certificate Application Instructions (OA 150-1). DMV does not accept applications via fax. APn. ITII AN U , OR dF S f Of Elm A LICATION TYPE (check one) AUTHORITY TYPE REQUESTED ORIGINAL APPLICATION ❑ REMOVE LIMITATION/ ❑ ROKER - PASSENGER ❑ HOUSEHOLD GOODS (Fee Required with application) RESTRICTION BROKER -PROPERTY ❑ SIGHTSEEING IRP ACCOUNT NUMBER BASE STATE CONTRACT PASSENGER ❑ NO ❑ YES - list certificate / license type(s) and number(s) below. Certificate / License Type Certificate / License Certificate / License was: 11g,11ill''11 INII! III IIIA 12,11 BUST ESS I ORM I a'WRNW BUSINESS NAME (For Individual ap 'cant giye your full legal name) (check if applicable) FEDERAL TAX IDENTIFICATION NUMBER 5q r DENIED TRADE NAME ORD IN USINESS AS (if different from Business Name) r BUSINESS EETADDREfdSS (d r give P.O. Box) � CITY ' r r 5 VA Z CODE lill03 BUSINESS MAILING ADDRESS (if diffel ent from ab e) CITY STATE ZIP CODE COUNTY NAME (if Virginia Address) TELEPHONE NUMBER '.3y 16V 87 9� FAX NUMBER PRIMARY CONTACT PERSON &M TELEPHONE NUMBER FAX NUMBER PRIMARY CONTACT PFERSON TITLE PRIMARY CONTACT PERSON EMAI�f DDRESS g LA.E-% I n.� ; CC . -C r) 3A. BUSINESS ENTITY TYPE (check one) ❑ CORPORATION INDIVIDUAL ❑ OTHER Provide information requested below for all Provide additional information requested rove a informationrequeste a ow or all corporate officers and/or board members. below for yourself. general partners, managers or members. Virginia law requires DMV to determine if persons applying for operating authority are fit to provide the service. Information from driving records is one of the tools used to determine fitness. If any of the Individuals listed below holds a driver's license issued by another state, you must enclose a current CERTIFIED copy of that person's driving record with this application. 3B. LIST BUSINESS OFFICIALS: ISSUING STATE FULL LEGAL NAME TITLE DRIVER LICENSE NUMBER (certified copy required if no issued by VA) e 4;,. �ICENSEq/gCEi2 FICTEI�F,OI2 A �,ON, Does your business have NO - Skip to the next section IFTA LICENSE NUMBER BASE STATE . an IFTA or an IRP account? ❑ YES - enter applicable information IRP ACCOUNT NUMBER BASE STATE IRP ACCOUNT NUMBER BASE STATE Has your business or any official of the business had any type of local, state, or federal certificate or license denied, suspended, or revoked? ❑ NO ❑ YES - list certificate / license type(s) and number(s) below. Certificate / License Type Certificate / License Certificate / License was: Reason Number (check if applicable) DENIED SUSPENDED/REVOKED DENIED SUSPENDED/REVOKED OA 150 (10/10/2013) - Page 2 s OWN.,," FAx.�a ;5a,CtOMPLtI,A►V�CRC�.�.:. no BUSINESS NA (must match usln ss Name you gave In Section 2) that I am in compliance with the Worker's Compensation Act of Title 65.2 and with the Business, Professional, and Occupational License Tax requirements. I BUSINESSSTfQ T A RES (must match Address you gave in Section 2) CITY JJrr L if ST99T ZIP CODE 8; r r�o4eJV1 license issued to me can be suspended and revoked if any of the information in the application is found to be untrue or inaccurate. INFORMATIONTHE FOLLOWING .ZONING APPLICANT OR AUTHORIZED REPRESENTATIVE TITLE Vjkt'r Virginia Code requires that the primary business location of the above named applicant must be in compliance with local zoning regulations before this application can be processed by DMV. Please provide all of the following information for the address listed above. ``" � „`� _ IN TAX MAP NUMBER LOT NUMBER SECTION ZONI DESIG ION 5 / v� b a Ku s I verify that the business location listed above is in compliance with the zoning ordinances of this city/county. ZONING FFI IAL NAME (print) ZONING pyFiqlAL SIGNATURE DATE( m/dd/ y y) &D Q AMOUNT TO BE CHARGED $50.00 c o ZONING OFFICIAL EMAIL ADDRE r . MBER For application type "REMOVE LIMITATION / RESTRICTION", enter limitation or restriction information to remove. � is+ M .' ioe.wi "ASO .rtd u.: ixis=:1 3� I certify that I will comply with all of the applicable provisions of the Code of Virginia, Title 46.2, and with all applicable requirements prescribed by the Virginia Department of Motor Vehicles. I affirm that all taxes, fees, penalties, interest, and judgements due the Commonwealth of Virginia have been paid or satisfied and that I am in compliance with the Worker's Compensation Act of Title 65.2 and with the Business, Professional, and Occupational License Tax requirements. I further certify and affirm that all information presented In this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation Is true and accurate. I make these certifications and affirmations under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation. I understand that any Virginia Operating Authority certificate or license issued to me can be suspended and revoked if any of the information in the application is found to be untrue or inaccurate. APPLICANT OR AUTHO IZED REPRESENTATIVE NAME APPLICANT OR AUTHORIZED REPRESENTATIVE TITLE Vjkt'r APPLICANT OR AU 19 RIZED EP SE TATIVE SIGNATURE DATE (mm/dd/yyyy) ``" � „`� _ IN 1.7 O VOID DELAYS in processing your application, review instructions OA 150-1 to ensure you have completed this application correctly. Applicants that have APPLICATION TYPE "Original Application" must include a NON-REFUNDABLE $50.00 fee with this application. If this application must be returned to you for any reason, you may be required to pay another $50.00 filing fee. PAYMENT METHOD: F-1CHECK-- Made payable to DMV ❑ MONEY ORDER -- Made payable to DMV CREDIT CARD — complete the credit card information below. NAME APPEARING ONC EDIT CARD DAYTIME TELEPHONE NUMBER �� r CREDIT ARD NUMBER O / v� b EXP RES (mm/yy) Z I / D AMOUNT TO BE CHARGED $50.00 I authorize DMV to charge the CARD HOLD NATURE credit card account listed above.