Form Rv F1315701 – Fill Out and Use This PDF

Tennessee Department of Revenue

Vehicle Services Division

Motor Carrier Section

44 Vantage Way, Suite 160

Nashville, Tennessee 37243-8050

APPLICATION FOR INTRASTATE AUTHORITY

One Time Registration Fee			$50.00
Name Change Fee			$25.00
Total Number of Vehicles
$8.00 Per Vehicle			$
Total Amount Due			$

FEIN/SSN:

US DOT Number:

Please indicate the type of authority for which this application is being made pursuant to Tennessee Code Annotated 65-15-109, and 65-15-110.

General Freight

Household Goods

Contract Hauler

Mobile Homes

For-Hire Towing, Wreckers and Car-Carriers

Private Towing, Wreckers and Car-Carriers

Bus-15 passengers or less

Bus-16 passengers or more

Hazardous Materials:

Carrier hauls hazardous materials that require $1 million limit of liability.

Carrier hauls hazardous materials that require $5 million limit of liability.

Applicant Name:

DBA (if applicable):

Physical Address:

		City			State			Zip Code
Mailing Address:
		City			State			Zip Code
Telephone Number:					Fax Number:

CONTINUE ON BACK OF DOCUMENT

RV-F1315701 (Rev. 11-13)

Company Structure (Check One)
		Individual			Partnership			Limited Liability Company			Corporation
List name of partners or officers:
Name:								Title:
Name:								Title:

Section I - Insurance Requirements

FORMS MUST BE SUBMITTED BY THE INSURANCE COMPANY.

Minimum Liability Coverage in the amount of $300,000 if gross vehicle weight rating is 26,000 pounds or less, $750,000 if gross vehicle weight rating is in excess of 26,000.

•Form E along with a MCS 90 Insurance Endorsement

•Form H - Cargo (Minimum of $5,000) Note: Private Towing, Wrecker Services and Car-Carriers do not need this form.

•Passenger Carriers - Form E and MCS-90

•15 or less passengers ($1,500,000)

•16 or more passengers ($5,000,000)

•Name of Insurance Company:

•Name of Insurance Representative:

•Telephone Number of Insurance Company:

•Fax Number of Insurance Company:

•E-mail Address of Insurance Company:

Section II - A copy of the Designation for Service of Process form must be a Tennessee Resident.

Section III - Penalty of Perjury Statement

Under penalty of perjury the undersigned declares that the information on this application is true and correct and that I am authorized to execute and file this document on behalf of the above applicant.

Signature

Title

Date

Section IV - Remittance

•Application must accompany fee

•Return your application with payment to the address shown below: “NO CASH” Tennessee Department of Revenue

500 Deaderick Street

Andrew Jackson State Office Building Nashville, TN 37242

Should you have any questions please call this office at 615-399-4266 or fax 615-361-8249.

ProcessingAccount Code 280.00