Hsmv 85900 Form PDF Details

Navigating the complexities of commercial vehicle operations and registration in Florida requires familiarity with the HSMV 85900 form, a comprehensive document that serves multiple purposes for fleet management. This form is an essential tool for businesses and individuals involved in the transportation sector, catering to a wide range of needs including the application for original titles, transfer of ownership, renewal of registration, adjustments in fleet composition, and correction of vehicular information. Not limited to the state of Florida, it also facilitates participation in the International Registration Plan (IRP), which harmonizes registration requirements and payments for commercial vehicles operating across state lines. Essential for ensuring compliance with the Department of Highway Safety and Motor Vehicles (DHSMV), the form requires detailed information on the type of operation, such as for-hire carriers, private carriers owning goods being transported, exempt commodity carriers, and household goods carriers. Additionally, it mandates the provision of vehicle and registrant details, including but not limited to, U.S. DOT number, fleet and vehicle specifics, fuel type, and weight categories. Moreover, it includes a checklist for documentation verification, such as proof of established place of business, payment of heavy vehicle use tax, and liability insurance, ensuring that all commercial vehicles meet Florida's safety, financial responsibility, and operational standards. Therefore, accurately completing and understanding the implications of the HSMV 85900 form is vital for seamless commercial vehicle management and operational legality within and beyond Florida's borders.

QuestionAnswer
Form NameHsmv 85900 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesflorida irp title, florida irp application form, application florida registrant, hsmv 85900

Form Preview Example

 

NAME OF REGISTRANT:

 

 

 

 

 

 

 

PLEASE TYPE OR PRINT WITH INK

 

 

 

 

 

 

 

 

 

(Select one choice):

 

 

 

 

 

 

 

 

 

 

TYPE OF OPERATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FLORIDA BUSINESS ADDRESS (NO NOT USE P. O. BOX):

 

 

 

 

 

INTERNATIONAL REGISTRATION PLAN

 

 

 

EXEMPT COMMODITY CARRIER

 

 

 

 

 

HOUSEHOLD GOODS CARRIER

 

 

 

 

 

 

 

 

 

 

 

 

 

FLORIDA APPLICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

COUNTY

STATE

 

ZIP CODE

SCHEDULE A

 

 

 

FOR HIRE CARRIER

 

 

 

 

 

PRIVATE CARRIER (OWNS GOODS

 

 

 

 

 

 

FLORIDA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BEING TRANSPORTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS

(

REGISTRANT’S):

See Below for Service Provider Information  

 

 

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

 

 

 

 

 

 

 

 

 

(Check as applies):

 

 

 

 

 

 

TYPE OF APPLICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

BUREAU OF COMMERCIAL VEHICLE AND DRIVER SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

COUNTY

STATE

 

ZIP CODE

2900 Apalachee Parkway, MS-62

 

 

 

ORIGINAL

 

 

 

 

 

 

TRANSFER

 

 

 

 

 

 

 

 

 

 

 

 

 

Tallahassee, Florida 32399-6552

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSON TO CONTACT REGARDING APPLICATION:

 

 

 

 

 

Telephone (850) 617-3711

 

 

 

RENEWAL

 

 

 

 

 

 

INCREASE WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

http://www.flhsmv.gov

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMAIL ADDRESS

(CVISN ACCOUNTS MUST HAVE AN EMAIL ADDRESS)

:

 

 

 

 

 

 

ADD FLEET

 

 

 

 

 

 

FLEET TO FLEET TRANSFER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF THE ABOVE ADDRESSES OR TELEPHONE NUMBER ARE DIFFERENT FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CORRECTION (TYPE OF CORRECTION):

 

WHAT WAS ON YOUR PREVIOUS APPLICATION, PLEASE CHECK and include

 

 

 

 

 

 

 

ADD VEHICLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 PROOFS OF ESTABLISHED PLACE OF BUSINESS with 85900 IRP Application:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REGISTRANT’S TELEPHONE NUMBER:

U.S. DOT NUMBER:

Registrant’s FEI # (THIS # IS REQUIRED TO REFERENCE YOUR IFTA ACCOUNT):

IRP ACCOUNT NUMBER:

FLEET NUMBER:

LICENSE YEAR:

COLORADO LOW MILEAGE – Check (√ ) any vehicle traveling in Colorado that will travel

less than 10,000 miles total in all jurisdictions in the column under COLO. LOW MILES.

  VEHICLE INFORMATION  

TRANSACTION TYPES:

A – ADD VEHICLE

C – CORRECTION

D – DELETE VEHICLE

O – ORIGINAL R – RENEWAL

VEHICLE TYPES:

TT - TRUCK TRACTOR

TK – TRUCK (SINGLE)

 

TR – TRACTOR

BS – BUS

FUEL TYPES: D – DIESEL G – GAS P - PROPANE

TRANS- OWNER’S

ACTION UNIT

TYPE NUMBER

YEAR

M A K E

VEHICLE

IDENTIFICATION

NUMBER

T Y P E

# OF

AXLES POWER UNIT

# OF

AXLES TRAILER

BUS

SEATS

F U E L

COLO.

LOW

MILES

C O L O R

GROSS OR COMBINED GROSS WEIGHT

EMPTY WEIGHT

DATE OF

PURCHASE

(M / D / Y)

OWNER’S

PURCHASE

PRICE

FLORIDA

TITLE

NUMBER

CARRIER RESPONSIBLE FOR VEHICLE SAFETY

U.S. DOT

TAX PAYER

WILL THE DESIGNATED

NUMBER

IDENTIFICATION NUMBER

CARRIER RESPONSIBLIE

ASSIGNED

(EIN, SSN)

FOR SAFETY CHANGE

TO VEHICLE

ASSIGNED TO VEHICLE

DURING THE YEAR?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 PROOFS OF ESTABLISHED PLACE OF BUSINESS

(

new account or address change only)

 

 

NAME OF CARRIER SERVICE PROVIDER (If Applicable) (

USE FOR MAILING ADDRESS

) Check this BOX

 

 

 

 

 

 

PLEASE BE SURE

 

PROOF OF PAYMENT OF HEAVY VEHICLE USE TAX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IRS FORM 2290 in Registrant’s or Title owner’s name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOU PRINTED YOUR NAME,

PROOF OF BODILY INJURY AND PROPERTY DAMAGE LIABILITY INSURANCE WITH PIP

 

ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(referred to as Combined Single Limits – CSL) with the DHSMV as Certificate Holder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNED THE APPLICATION,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROOF OF OWNERSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AND ENCLOSED THE

OUT OF STATE TITLES MUST HAVE COPY OF CLEAR TITLE FRONT AND BACK OR A COPY OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY:

COUNTY:

 

STATE:

 

ZIP CODE:

 

 

 

 

 

FOLLOWING REQUIRED

THE RECEIPT FOR THE ELECTRONIC TITLE, VIN VERIFICATION FORM AND A LETTER FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE LIEN-HOLDER OR LEASE AGREEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOCUMENTATION, AS NECESSARY.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COPY OF LEASE, IF APPLICABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HSMV 85900 (Rev. 10/2014)

SCHEDULE B – MILEAGE INFORMATION AND WEIGHT

 

 

 

 

 

 

ENTER ACTUAL MILES TRAVELED BY FLEET

 

Will you be operating intrastate in the state of Wyoming?

UNITS LISTED WILL BE AUTHORIZED TO

 

 

 

 

VEHICLES FOR THE PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPERATE AT THE WEIGHTS LISTED BELOW

JULY 1,

 

THROUGH JUNE 30,

 

 

YES

NO

(Please one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JURISDICTION

ACTUAL

GVW

 

JURISDICTION

 

 

ACTUAL

 

 

GVW

 

JURISDICTION

ACTUAL

 

 

GVW

MILES

 

 

 

MILES

 

 

 

MILES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FL – FLORIDA

 

 

 

MI – MICHIGAN

 

 

 

 

 

 

 

 

TX – TEXAS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AL – ALABAMA

 

 

 

MN – MINNESOTA

 

 

 

 

 

 

 

 

UT – UTAH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AK - ALASKA

 

 

 

MO – MISSOURI

 

 

 

 

 

 

 

 

VA – VIRGINIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AR – ARKANSAS

 

 

 

MS – MISSISSIPPI

 

 

 

 

 

 

 

 

VT – VERMONT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AZ – ARIZONA

 

 

 

MT – MONTANA

 

 

 

 

 

 

 

 

WA – WASHINGTON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CA – CALIFORNIA

 

 

 

NC – NORTH CAROLINA

 

 

 

 

 

 

 

 

WI – WISCONSIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CO – COLORADO

 

 

 

ND – NORTH DAKOTA

 

 

 

 

 

 

 

 

WV – WEST VIRGINIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CT – CONNECTICUT

 

 

 

NE – NEBRASKA

 

 

 

 

 

 

 

 

WY – WYOMING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DC – DIST. OF COLUMBIA

 

 

 

NH – NEW HAMPSHIRE

 

 

 

 

 

 

 

 

AB – ALBERTA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DE – DELAWARE

 

 

 

NJ – NEW JERSEY

 

 

 

 

 

 

 

 

BC – BRITISH COLUMBIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GA – GEORGIA

 

 

 

NM – NEW MEXICO

 

 

 

 

 

 

 

 

MB – MANITOBA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IA – IOWA

 

 

 

NV – NEVADA

 

 

 

 

 

 

 

 

MX – MEXICO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID – IDAHO

 

 

 

NY – NEW YORK

 

 

 

 

 

 

 

 

NB – NEW BRUNSWICK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL – ILLINOIS

 

 

 

OH – OHIO

 

 

 

 

 

 

 

 

NL – NEWFOUND/LABRA.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN – INDIANA

 

 

 

OK – OKLAHOMA

 

 

 

 

 

 

 

 

NS – NOVA SCOTIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KS – KANSAS

 

 

 

OR – OREGON

 

 

 

 

 

 

 

 

NT – NW TERRITORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KY – KENTUCKY

 

 

 

PA – PENNSYLVANIA

 

 

 

 

 

 

 

 

ON – ONTARIO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LA – LOUISIANA

 

 

 

RI – RHODE ISLAND

 

 

 

 

 

 

 

 

PE – PRINCE ED. ISL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MA – MASSACHUSETTS

 

 

 

SC – SOUTH CAROLINA

 

 

 

 

 

 

 

 

QC – QUEBEC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD – MARYLAND

 

 

 

SD – SOUTH DAKOTA

 

 

 

 

 

 

 

 

SK – SASKATCHEWAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ME - MAINE

 

 

 

TN – TENNESSEE

 

 

 

 

 

 

 

 

YT - YUKON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Application for apportioned registration is a declaration of knowledge that Florida has adopted the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

federal motor carrier safety regulations and federal hazardous material regulations and the

 

 

 

 

 

TOTAL THE ACTUAL MILES LISTED ABOVE AND ENTER HERE

 

 

 

 

 

registrant is familiar with the applicable requirements. I certify that the information furnished in

 

PLEASE DO NOT SEND MONEY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

this application and the attachments is true and correct and that I have read and understand the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO BE COMPLETED FOR

ORIGINAL

IRP APPLICATIONS ONLY:

 

 

 

 

 

records retention requirements for the International Registration Plan and will comply with them.

 

 

WITH THIS APPLICATION.

 

 

 

 

 

 

PRINTED NAME:

 

 

 

 

 

 

 

 

A BILL WILL BE CALCULATED

 

Does this fleet and/or vehicles have any history of prior IRP registration In another jurisdiction?

YES

NO

 

 

 

 

 

 

 

 

AND MAILED TO YOU.

 

SIGNATURE

 

 

 

 

 

 

 

 

 

What jurisdiction?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TITLE:

 

 

 

 

 

 

 

 

 

APPLICATIONS ARE

 

Does this fleet and/or vehicles have any history of prior Florida IRP Registration?

 

 

YES

NO

DATE:

 

 

 

 

 

 

 

 

WORKED ON FIRST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECEIVED BASIS

 

Has your registration ever been suspended or revoked?

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS APPLICATION MUST BE SIGNED BY THE REGISTRANT UNLESS REGISTRANT SUBMITS A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HSMV 96440 POWER OF ATTORNEY DESIGNATING THE PERSON SIGNING AS AN AUTHORIZED AGENT.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HSMV 85900 (Rev. 10/2014)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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