Irp 6 Form – Fill Out and Use This PDF

Irp 6 Form – Fill Out and Use This PDF

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IRP-6 (5/13)	New York State Department of Motor Vehicles		PAGE 1 OF 2
	INTERNATIONAL REGISTRATION PLAN
	SCHEDULEA& C
PART 1
	TYPE OFAPPLICATION REQUESTED
NEWACCOUNT	ADD JURISDICTIONS	DUPLICATE CAB CARD	ADDRESS CHANGE
ADD VEHICLE	WEIGHT INCREASE	REPLACEMENT PLATES	TEMPORARYAUTHORITY
DELETE VEHICLE	WEIGHT DECREASE	REPLACEMENT STICKER	OTHER____________________
TRANSFER PLATES	RENEWAL	FLEET TO FLEET
REGISTRANT/CARRIER INFORMATION			DMV USE ONLY
REGISTRANT/CARRIER INFORMATION
1. ACCOUNT # ____________________________________		2. FLEET # ____________________ SUPP#: __________________

3.REGISTRANT NAME: ____________________________________________________________________________________

4.DBA: __________________________________________________________________________________________________

5.BUSINESSADDRESS:____________________________________________________________________________________

		(No P.O. Box NumberAllowed)
	CITY: ______________________ STATE: _______	ZIP CODE: ______________ COUNTY:	______________________
6.	CONTACT PERSON: ______________________________________________ 7. PHONE # (		) ____________________
8.	TAXPAYER IDENTIFICATION # (TIN): _______________________FEIN SSN 9. FAX # (		) ____________________
10.	DATE OF BIRTH: ____________________ 11.	Male Female

12.PRIVACY ACT: Check the INFORMATION DISCLOSURE box at the end of this sentence if you do not want your personal information from this record used for surveys, marketing and solicitations.

13.WYAUTHORITY#:____________________________

14.SAFETY CARRIER’S NAME:

DOT#: ___________________________________________ TIN:
	Have you previously been registered in any jurisdictions? Yes			No, If yes, jurisdiction _________________________________
	Do you lease your vehicle and driver to a motor carrier?		Yes No
FLEET INFORMATION
15.	FLEET TYPE: ____	16. COMMODITY CLASS: ____		17. # OF REG MONTHS: ______
	18. EFFECTIVE DATE: _______________			19. EXPIRATION DATE: _____________
20.	MAILINGADDRESS: ______________________________________________________________________________________
			(No P.O. Box NumberAllowed)
	CITY: ______________________ STATE: _______		ZIP CODE: ______________ COUNTY: ________________________

PART 2

FLEET TO FLEET TRANSFER INFORMATION

(21)

(22)

(23)

(24)

FLEET VEHICLE UNIT #

(OEN)

VEHICLE IDENTIFICATION NUMBER

FROM FLEET #

TO FLEET #

DELETIONS*

(25)

(26)

(27)

(28)

FLEET VEHICLE UNIT #

(OEN)

VEHICLE IDENTIFICATION NUMBER

LICENSE	REPLACEMENT FLEET
PLATE NUMBER	VEHICLE UNIT # (OEN)

*(Send in plates for deletion.)

PART 3

WEIGHT

INFORMATION Account # ____________________________________

29.Please list the weight you want on your cab card for the jurisdictions you intend to travel through. Canadian jurisdictions will print the weight in kilograms on the cab card.

AK	____________________	KS	____________________	NJ	____________________	VT	____________________
AL	____________________	KY	____________________	NM	____________________	WA	____________________
AR	____________________	LA	____________________	NV	____________________	WI	____________________
AZ	____________________	MA	____________________	NY	____________________	WV	____________________
CA	____________________	MD	____________________	OH	____________________	WY	____________________
CO	____________________	ME	____________________	OK	____________________	AB	____________________ (Canada)
CT	____________________	MI	____________________	OR	____________________	BC	____________________ (Canada)
DC	____________________	MN	____________________	PA	____________________	MB	____________________ (Canada)
DE	____________________	MO	____________________	RI	____________________	NB	____________________ (Canada)
FL	____________________	MS	____________________	SC	____________________	NL	____________________ (Canada)
GA	____________________	MT	____________________	SD	____________________	NS	____________________ (Canada)
IA	____________________	NC	____________________	TN	____________________	ON	____________________ (Canada)
ID	____________________	ND	____________________	TX	____________________	PE	____________________ (Canada)
IL	____________________	NE	____________________	UT	____________________	QC	____________________ (Canada)
IN	____________________	NH	____________________	VA	____________________	SK	____________________ (Canada)
		VEHICLE INFORMATION FOR NEWACCOUNTS ORADDITIONS
	PART 4	VEHICLE INFORMATION FOR NEWACCOUNTS ORADDITIONS

30.VEHICLE #1:

A) VEHICLE IDENTIFICATION NUMBER

B) YEAR

MAKE

D) VEHICLE TYPE

E) FUEL/CYL

F) WHEELBASE

G) UNLADEN WT

H) SEATS

I) COMBINED

J) COLOR

K) OWNER NAME

/AXLES

AXLES

L) TITLE DOC #

M) TITLE DOC. JUR.

N) SAFETY TAXPAYER ID # (TIN)

FEIN SSN

O) SAFETY US DOT #

P) Vehicle Safety responsibility will change

Q) SAFETYNAME

during the year?

Yes

R) FLEET VEHICLE # (OEN)

S)MAXIMUM DESIRED WEIGHT

T)PURCHASE PRICE

U)PURCHASE DATE

V) FACTORY PRICE	W)INS. CO. CODE	X) CURRENT PLATE #	Y) CURRENT PLATE CLASS	Z) SPECIAL USE

REGISTRATION	IF THE REGISTRANT IS NOT THE OWNER, fill in the information below. Proof of ownership, and proof of the
AUTHORIZATION	OWNER’S name and date of birth, are required.
Vehicle #1 - Owner’s Name			Date of Birth			Is the vehicle leased?
						Yes No
Address	Apt. No.	City	State		Zip Code

The person named in number 3 of Part 1 is authorized to register this vehicle in his/her name.
Owner’sAuthorized
Signature -				Date:
Signature -				Date:

Ifsigningforacorporation,printyourfullnameandtitlehere

CERTIFICATION: I, the Undersigned, certify under penalty of perjury that all information provided in thisApplication is true and accurate to the

best of my knowledge, and that the subject vehicle: is fully equipped, inspected, insured, and will be operated, in compliance with NewYork State Vehicle and Traffic Law (VTL); possesses a valid NYS inspection issued within the last twelve (12) months; or, in the alternative, has qualified for an extension of such inspection (see, DMV form VS-1077) and will be inspected within the next ten (10) days; is covered by a current policy of insurance or financial security as required by VTL; and if previously “junked”, has been repaired to conform with VTL Sections 375 and 376; possesses a currently valid NYS registration (if I am using thisApplication to request issuance of replacement registration documents). I declare that IfullyunderstandapplicableFederalandNYSMotorVehicleCarrierSafetylawsandregulationsincluding,whereapplicable,thosepertainingtothe transportation of hazardous materials.If this Application is signed in my official capacity on behalf of a business entity, I further certify that I am dulyauthorizedtomakethisApplicationonbehalfofsuchentity.

IMPORTANT: By signing thisApplication, the Undersigned acknowledges that intentionally making a false statement on this form is a misdemeanor underVTLSection392,andmayresultincriminalprosecution,aswellassuspensionorrevocationoftheregistrationofthesubjectvehicle.

Name ofApplicant/Business Entity (please print):

Question	Answer
Form Name	Irp 6 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	New_York, IRP-6, irp6 form pdf, DMV

Sign here:-

Date (mm/dd/yyyy):

If signing as agent for a business entity, write your title (CEO, President, Vice-President, Secretary, Treasurer or Comptroller).

Anyone else signing as agent for a business entity must send in an original Power ofAttorney.

IRP-6 (5/13)

PAGE 2 OF 2