Fillable APPLICATION FOR COMMON CARRIERS OF PASSENGERS INSTRUCTIONS AND (Virginia Department of Motor Vehicles)

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APPLICATION FOR COMMON CARRIERS OF PASSENGERS INSTRUCTIONS AND (Virginia Department of Motor Vehicles)

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OA141-I (09/25/2020)
Selecting the correct "Application Type" is important as these selections impact how DMV will process your application. Application and authority types
available are defined below:
APPLICATION TYPES
ORIGINAL APPLICATION -- Select this application type if:
► you would like to obtain a For-Hire Intrastate Operating Authority
Common Carrier Regular/Irregular Route Certificate. You must
complete the following:
♦ Select appropriate AUTHORITY TYPE (see "Authority Types"
below for additional information.)
● If you selected Authority Type Common Carrier - REGULAR
ROUTE, complete sections 1 through 4, 6, 9 and 10.
● If you selected Authority Type Common Carrier - IRREGULAR
ROUTE, complete sections 1 through 4, 7, 9 and 10.
♦ Demonstrate public need – Your completed application (OA
141) serves as a request for a certificate of public convenience and
necessity which would authorize you to transport the general public
within Virginia as a common carrier over regular or irregular routes.
You will be required to publish a notice of your application in a
newspaper having circulation in the area you propose to serve or
where your business is located. DMV will provide you the required
content of this notice. A notice informing the public of your
application will also stay on the DMV website for two weeks. These
notices are required by Virginia Code. Interested persons that feel
they may be harmed by the issuance of the certificate of public
convenience and necessity you have requested may respond to
these notices by sending a written protest to both you as the
applicant and DMV. If the protest results in an administrative
hearing to determine whether or not the certificate of public
convenience and necessity should be issued, you would be
required to provide convincing evidence that the public needs your
proposed transportation service even if other licensed motor
carriers are already serving the area you propose to serve, and that
you have the motor vehicles and resources to serve the public at
their convenience throughout the entire area you propose to serve.
♦ ALL AUTHORITY TYPES
● You must submit the following items with your application:
- A $50.00 nonrefundable filing fee.
- A Surety Bond or Irrevocable Letter of Credit (Additional
information provided in the "Authority Types" section).
- A Power of Attorney document (from your surety company).
- Tariff (Additional information provided in the "Authority Types"
section).
ADD OR DELETE ROUTE / SERVICE AREA -- Select this application
type if:
► you currently have a valid For-Hire Intrastate Operating Authority
Certificate AND you would like to change the authorized routes or
service areas. You must complete the following:
♦ Select appropriate AUTHORITY TYPE (see "Authority Types"
below for additional information.)
SECTION 1 -- APPLICATION AND AUTHORITY TYPES
● If you selected Authority Type Common Carrier - REGULAR
ROUTE, complete sections 1, 2, 6 and 9.
● If you selected Authority Type Common Carrier - IRREGULAR
ROUTE, complete sections 1, 2, 7 and 9.
♦ Submit a copy of your certificate
♦ If your application is approved, you will be required to provide
DMV with an updated tariff (Additional information provided in the
"Authority Types" section).
♦ Demonstrate public need - See Instructions for Original
Application.
REMOVE LIMITATION / RESTRICTION -- Select this application type if:
► you currently have a For-Hire Intrastate Operating Authority Certificate
AND you would like to remove certain limitations or restrictions from
the certificate . You must complete the following:
♦ Select appropriate AUTHORITY TYPE (see "Authority Types"
below for additional information.)
♦ Complete sections 1, 2, 8 and 9.
♦ Submit a copy of your certificate
♦ If your application is approved, you will be required to provide
DMV with an updated tariff (Additional information provided in the
"Authority Types" section).
♦ Demonstrate public need - See Instructions for Original
Application.
TRANSFER / SALE -- Select this application type if:
► you are purchasing or receiving via transfer a For-Hire Intrastate
Operating Authority Common Carrier Regular/Irregular Route
Certificate from another party. You must complete the following:
♦ Select the AUTHORITY TYPE of the certificate you are
purchasing or receiving via transfer.
♦ If you currently hold a For-Hire Intrastate Operating Authority
Certificate of ANY type, complete sections 1, 2, 5, 9 and 10.
♦ If you do NOT currently hold a For-Hire Intrastate Operating
Authority Certificate, complete sections 1 through 5, 9 and 10.
♦ ALL AUTHORITY TYPES
● You must submit the following items with your application:
- A $50.00 nonrefundable filing fee.
- A Surety Bond or Irrevocable Letter of Credit (Additional
information provided in the "Authority Types" section).
- A Power of Attorney document (from your surety company).
- Tariff (Additional information provided in the "Authority Types"
section).
ALL APPLICATION TYPES - DMV does not accept applications via fax.
OPERATING AUTHORITY CERTIFICATE
APPLICATION FOR COMMON CARRIERS OF PASSENGERS
INSTRUCTIONS AND APPLICATION
Purpose: Use this form to apply for or change existing authority to operate as a Common Carrier over Regular Routes or a Common Carrier over Irregular
Routes in Virginia. For information on how to obtain For-Hire Intrastate Operating Authority for other types of for-hire services, visit
www.dmvNow.com.
Instructions: To ensure accurate and timely processing of your application, read and follow all steps outlined in the instructions that follow PRIOR to
completing the application.
NOTE: The application process for operating authority involves multiple steps, including the submission of various pieces of information, and requires
the applicant's continuing involvement and cooperation with DMV staff. It is critical that all required information is current and that it is submitted
timely. If after 90 days you have failed to respond to a request for information, DMV may cancel your application. If your application has been
canceled and you later decide to reapply for operating authority, you will need to begin the process as a new applicant.
Please be aware of the following prohibition: If you have been or are found guilty of performing, offering, advertising, providing, procuring,
or arranging by contract, agreement, or arrangement to transport passengers for compensation without the required license, permit, or
certificate through either a conviction resulting from a Virginia Uniform Summons or a civil penalty appropriately assessed by DMV, you will be
denied the license, permit, or certificate requested for a period of 12 months beginning from the date of the conviction or assessment of the civil
penalty.
OA141-I (09/25/2020)
Page 2 of Instructions
NOTE: For additional instructions review form OA435 -
Passenger Carrier and Passenger Broker Bond or form
OA447 - For Hire Operating Authority Certificate or License,
Irrevocable Letter of Credit located under "Forms and
Publications" on dmvNow.com.
♦ If your application is approved, you will be required to have
proof of liability insurance filed with DMV by your insurance
company. Required minimum amounts are as follows:
Minimum Bodily Injury and
Property Damage Amount
Total Passengers
(including driver)
$350,000 1 to 6
$1,500,000 7 to 15
$5,000,000 16 or more
COMMON CARRIER - IRREGULAR ROUTE -- Select this authority type if:
► you would like to obtain OR you are changing, purchasing or receiving via transfer a For-Hire Intrastate Operating Authority Certificate to transport
the general public for individual fees by motor vehicle over any route(s) in pre-determined areas of Virginia. The following requirements MUST be
met:
NOTE: For additional instructions review form OA435 -
Passenger Carrier and Passenger Broker Bond or form
OA447 - For Hire Operating Authority Certificate or
License, Irrevocable Letter of Credit located under "Forms
and Publications" on dmvNow.com.
♦ If your application is approved, you will be required to have
proof of liability insurance filed with DMV by your insurance
company. Required minimum amounts are as follows:
♦ Vehicles used MUST be designed to carry 15 passengers or
less (including driver).
♦ You can only operate in the areas of Virginia that will be listed
on your certificate.
♦ You must file a tariff showing all rates and charges for the
transportation you provide and any rules and regulations you will
require your customers to follow as they relate to your
transportation services.
NOTE: For additional instructions and a sample tariff, review
form OA-448 located under "Forms and Publications" on
DMVNow.com.
♦ You must maintain a surety bond in the amount of $25,000.
The bond must be kept in effect for 3 years from the issue date of
the operating authority certificate.
Minimum Bodily Injury and
Property Damage Amount
Total Passengers
(including driver)
$350,000 1 to 6
$1,500,000 7 to 15
Complete all fields in this section as described below:
BUSINESS NAME - enter the legal name used to register your business.
FEDERAL TAX IDENTIFICATION NUMBER - Internal Revenue Service
assigned number that identifies your business entity.
TRADE NAME OR DOING BUSINESS AS - enter the name by which
people know your business. Only complete this field if this name is
different than your "Business Name".
BUSINESS STREET ADDRESS - enter the street number and name of
your business' physical location. This location must be where the routine
day to day operations of the business are conducted, owned or leased by
the applicant, satisfy all applicable local zoning regulations, houses all
records, and be equipped with a working telephone listed in the business
name.
CITY - enter the city name of your business' physical location.
STATE - enter the state name of your business' physical location.
ZIP CODE - enter the postal zip code for your business' physical location.
BUSINESS MAILING ADDRESS - enter the mailing address (street
number and name OR P.O. Box) for your business. Only required if
different than business' physical location.
CITY - enter the city of the mailing address for your business.
STATE - enter the state of the mailing address for your business.
SECTION 2 -- BUSINESS INFORMATION
ZIP CODE - enter the postal zip code of the mailing address for your
business.
COUNTY NAME - if your business is located in Virginia, enter the county
name for the business' physical location (if applicable).
BUSINESS TELEPHONE NUMBER - the number at which your business
can be reached during business hours, this number must be listed or
advertised in the name of the business.
BUSINESS FAX NUMBER - FAX transmissions sent to the physical
location of your business will use this number.
PRIMARY CONTACT PERSON NAME - enter the name of the person
who will serve as the primary DMV contact for any questions regarding
your application or business.
PRIMARY CONTACT TELEPHONE - enter the best number to reach the
primary contact person listed for your business.
PRIMARY CONTACT FAX NUMBER - enter the best number to send
FAX transmissions to the business' primary contact person.
PRIMARY CONTACT PERSON TITLE - enter the official business title of
the business' primary contact person.
PRIMARY CONTACT EMAIL ADDRESS - enter the email address for the
business' primary contact person.
AUTHORITY TYPES
COMMON CARRIER - REGULAR ROUTE -- Select this authority type if:
► you would like to obtain OR you are changing, purchasing or receiving via transfer a For-Hire Intrastate Operating Authority Certificate to transport
the general public for individual fees by motor vehicle over pre-defined route(s) in Virginia. The following requirements MUST be met:
♦ You must:
● provide your services to the general public
● operate on the routes that will be listed on your certificate.
● file a tariff showing all rates and charges for the transportation
you provide and any rules and regulations you will require your
customers to follow as they relate to your transportation services.
● file a time schedule.
NOTE: For additional instructions and samples of tariffs and
time schedules, review form OA-449 located under
"Forms and Publications" on DMVNow.com.
● maintain a surety bond in the amount of $25,000. The bond
must be kept in effect for 3 years from the issue date of the
operating authority certificate.
OA141-I (09/25/2020)
Page 3 of Instructions
SECTION 4 -- LICENSE / CERTIFICATE INFORMATION
Answer questions in this section accurately and provide additional information as appropriate.
CERTIFICATE, LICENSE OR PERMIT NUMBER - enter the certificate,
license or permit number(s) associated with the operating authority that you
currently hold or have previously held.
IRP ACCOUNT NUMBER / IFTA LICENSE NUMBER - enter the IRP
account number(s) or IFTA license number that you currently hold or have
previously held.
BASE STATE - enter the name of the jurisdiction that serves as your base
state for IFTA/IRP.
CERTIFICATE / LICENSE TYPE - if your business has had an operating
authority certificate or license denied, suspended or revoked, enter the type
of certificate or license that was denied, suspended or revoked.
CERTIFICATE / LICENSE NUMBER - enter the certificate or license
number(s) associated with the denial, suspension or revocation.
CERTIFICATE / LICENSE WAS - Check appropriate box to indicate if your
certificate or license was denied, suspended or revoked.
REASON - enter the reason why your certificate or license was denied,
suspended or revoked.
You must complete this section if:
► your APPLICATION TYPE is "ORIGINAL" or "ADD OR DELETE ROUTE / SERVICE AREA" AND;
► your AUTHORITY TYPE is "COMMON CARRIER -- REGULAR ROUTE"
SECTION 6 -- VIRGINIA TRAVEL INFORMATION
VIRGINIA TRAVEL INFORMATION - use the space provided to detail the
route(s) you are requesting:
♦ List the name of the location and address in the Virginia city or
county where your trip will begin and end
♦ List each and every street, road, etc. that will be traveled during
each trip
CERTIFICATE NUMBER TO AMEND - If your APPLICATION TYPE is
"ADD OR DELETE ROUTE / SERVICE AREA", enter the for-hire
operating authority certificate number you are changing.
TO DELETE A ROUTE OR SERVICE AREA - when deleting a route or
service area, begin the route or service area with "DELETE -"
SECTION 5 -- TRANSFER / SALE INFORMATION
Complete this section only if your APPLICATION TYPE is Transfer/Sale. The current certificate holder or an authorized representative must also
provide information and certification via signature in this section.
CURRENT CERTIFICATE HOLDER NAME - enter the name of the
individual or business that currently holds the for-hire operating authority
certificate.
CERTIFICATE NUMBER - enter the for-hire operating authority certificate
number being purchased.
BUSINESS MAILING ADDRESS - enter the mailing address (street
number and name OR P.O. Box) of the individual or business
transferring/selling the for-hire operating authority certificate.
CITY - enter the mailing address' city of the individual or business
transferring/selling the for-hire operating authority certificate.
STATE - enter the mailing address' state of the individual or business
transferring/selling the for-hire operating authority certificate.
ZIP CODE - enter the mailing address' postal zip code of the individual or
business transferring/selling the for-hire operating authority certificate.
BUSINESS TELEPHONE NUMBER - enter the telephone number of the
individual or business transferring/selling the for-hire operating authority
certificate.
BUSINESS FAX NUMBER - enter the number used for FAX
transmissions for the individual or business transferring/selling the for-
hire authority certificate.
PRIMARY CONTACT PERSON NAME - enter the name of the person
who will serve as the primary DMV contact for the individual or business
transferring/selling the for-hire authority certificate.
PRIMARY CONTACT TELEPHONE - enter the best number to reach the
primary contact person listed for the individual or business transferring/
selling the for-hire authority certificate.
You must complete this section if:
► your APPLICATION TYPE is "ORIGINAL" or "ADD OR DELETE ROUTE / SERVICE AREA" AND;
► your AUTHORITY TYPE is "COMMON CARRIER -- IRREGULAR ROUTE"
SECTION 7 -- TRAVEL JURISDICTIONS INFORMATION
Check the box next to each city and county you plan to travel through.
You must be able to drive a connecting route through the neighboring
cities/counties selected or your application will be returned.
TO ADD OR DELETE CITIES / COUNTIES - check the box next to each
city and/or county you would like to add or delete. Write "A" to add or "D"
to delete next to the city and/or county in the space provided.
SECTION 3 -- BUSINESS ENTITY INFORMATION
BUSINESS ENTITY TYPE - check to indicate if your business is structured
as a corporation or other entity type.
LIST BUSINESS OFFICIALS - enter requested information for all required
business officials as determined by your entity type.
OA141-I (09/25/2020)
Page 4 of Instructions
Carefully read this section, then sign and date where indicated.
SECTION 9 -- CERTIFICATION
Payment must be submitted with the application if:
► your APPLICATION TYPE is "ORIGINAL" or "TRANSFER / SALE"
A $50.00 non-refundable fee must be included with the above application types. If this application is returned to you, you may be required to pay
another $50.00 filing fee.
SECTION 10 -- PAYMENT METHODS
CONTACT INFORMATION
If you have additional questions or need assistance, you can contact a Motor Carrier Services Representative at:
804-249-5130 (voice) (800) 272-9268 (deaf and hearing impaired only)
(804) 367-1058 (fax) mcsonline@dmv.virginia.gov (e-mail)
SECTION 8 -- REMOVE LIMITATION / RESTRICTION INFORMATION
You must complete this section if:
► your APPLICATION TYPE is REMOVE LIMITATION / RESTRICTION
Limitations and restrictions are based on fitness at time of initial application. In order to remove limitations and/or restrictions, you will be required to
prove by competent evidence that your fitness to provide the transportation service has risen to a level that makes the restriction/limitation unjustified.
Removal of limitations/restrictions may require a DMV Administrative Hearing.
OA 141 (04/24/2018)
BUSINESS STREET ADDRESS (do not give P.O. Box)
CITY
ZIP CODESTATE
FEDERAL TAX IDENTIFICATION NUMBERBUSINESS NAME
2. BUSINESS INFORMATION
TRADE NAME OR DOING BUSINESS AS (if different from Business Name)
BUSINESS MAILING ADDRESS (if different from above)
CITY
ZIP CODESTATE
COUNTY NAME (if Virginia Address) TELEPHONE NUMBER FAX NUMBER
PRIMARY CONTACT PERSON NAME FAX NUMBERTELEPHONE NUMBER
PRIMARY CONTACT PERSON TITLE PRIMARY CONTACT PERSON EMAIL ADDRESS
1. APPLICATION AND AUTHORITY TYPES
APPLICATION TYPE (check one)
AUTHORITY TYPE REQUESTED
ORIGINAL APPLICATION
(Fee Required with application)
TRANSFER / SALE
(Fee Required with application)
ADD OR DELETE ROUTE /
SERVICE AREA
REMOVE LIMITATION /
RESTRICTION
COMMON CARRIER -- REGULAR ROUTECOMMON CARRIER -- IRREGULAR ROUTE
OPERATING AUTHORITY CERTIFICATE APPLICATION
FOR COMMON CARRIERS OF PASSENGERS
3. BUSINESS ENTITY INFORMATION
Virginia law requires DMV to determine if persons applying for operating authority are fit to provide the service. Va. Code §19.2-389(30) authorizes the release
of criminal history information to DMV in order to evaluate certificate/license applicants. In addition, DMV will review your driving record. The information
requested below must be provided for:
l The owner of the business if you are applying as a sole proprietor (individual),
l Each partner of the business if applying as a partnership, limited partnership (LP), or limited liability partnership (LLP),
l Each member and /or manager if applying as a limited liability company (LLC), or
l Each officer if applying as a corporation.
If any of the business officials listed below holds a driver's license issued by a state other than Virginia, you must enclose a current CERTIFIED copy of that
person's driving record with this application.
FULL LEGAL NAME
DRIVER LICENSE
NUMBER
ISSUING STATE
(certified copy required
if not issued by VA)
DATE OF BIRTH
SOCIAL SECURITY
NUMBER
4. LICENSE / CERTIFICATE INFORMATION
Does your business have
an IFTA or an IRP account?
YES - enter applicable information
NO - Skip to the next question
IFTA LICENSE NUMBER BASE STATE
IRP ACCOUNT NUMBER BASE STATE IRP ACCOUNT NUMBER BASE STATE
YES - list certificate / license type(s) and number(s) below.NO
Has your business or any official of the business had any type of local, state, or federal certificate or license denied, suspended, or revoked?
Certificate / License Type
Certificate / License
Number
Certificate / License was:
(check if applicable)
Reason
SUSPENDED/REVOKED
DENIED
SUSPENDED/REVOKED
DENIED
Have you as a sole proprietor, or a partner, or the business name provided above, or any business official listed above, ever been convicted or assessed a civil
penalty for operating, offering, advertising, providing, procuring, furnishing or arranging to transport passengers for compensation without first obtaining a license,
permit or certificate from DMV?
YES - provide additional detail below.NO
FULL LEGAL NAME
CONVICTION
CIVIL PENALTY
COURT(if conviction)
FULL LEGAL NAME
CONVICTION
CIVIL PENALTY
COURT(if conviction)
OA 141 (04/24/2018) -- Page 2
5. TRANSFER / SALE INFORMATION
CURRENT CERTIFICATE HOLDER NAME CERTIFICATE NUMBER
ZIP CODESTATE
CITY
BUSINESS MAILING ADDRESS
BUSINESS FAX NUMBERBUSINESS TELEPHONE NUMBER PRIMARY CONTACT PERSON NAME TELEPHONE NUMBER
The following information MUST be completed by the current certificate holder or their authorized representative.
Are you selling all of the business to the applicant named in Section 2, "Business Information" of this application?
I certify that I currently hold a valid Virginia operating authority certificate and that I have agreed to transfer / sell the certificate to the applicant named in Section
2, "Business Information" of this application. I further certify that all the information provided in the "Transfer / Sale" section of this application is true and correct.
YESNO
DATE (mm/dd/yyyy)
TITLECURRENT CERTIFICATE HOLDER OR AUTHORIZED REPRESENTATIVE FULL NAME (print)
CURRENT CERTIFICATE HOLDER OR AUTHORIZED REPRESENTATIVE SIGNATURE
Complete for APPLICATION TYPE TRANSFER / SALE
6. VIRGINIA TRAVEL INFORMATION
Complete for AUTHORITY TYPE Common Carrier -- Regular Route & APPLICATION TYPES Original or Add or Delete Route / Service Area
• If application type is ADD OR DELETE ROUTE / SERVICE AREA -- list only new OR amended trip information.
If you wish to delete a route / service area, precede the route's / service area's description with "DELETE - " . . .
• If application type is ORIGINAL APPLICATION -- list the name of the location and address in the Virginia city or county where your trips will begin and end and
each and every street, road, etc. that you travel during each trip.
Example: Trip 7 - Start from Four Mile Mall north parking lot at 410 Four Mile Rd. in Alexandria, travel northwest 3 blocks to I-395 South, travel 6 miles to I-95
south, travel 93.4 miles to Boulevard exit in Richmond City, turn right onto Boulevard, travel 6 blocks to end of trip 1234 Boulevard in Richmond City.
CERTIFICATE NUMBER TO AMEND
OA 141 (04/24/2018) -- Page 3
7. TRAVEL JURISDICTIONS INFORMATION
Complete for AUTHORITY TYPE Common Carrier -- Irregular Route & APPLICATION TYPES Original or Add or Delete Route / Service Area
Check the box next to EACH city and county you plan to travel through. You must be able to drive a connecting route through the neighboring cities / counties
you selected or your application will be returned.
For example, if you plan to travel from Charlottesville to Petersburg you would check the following cities and counties if you were traveling on routes I-64 and
I-95: Charlottesville City, Albemarle County, Fluvanna County, Louisa County, Goochland County, Henrico County, Richmond City, Chesterfield County, Colonial
Heights City, and Petersburg City.
NOTE: For APPLICATION TYPE "ADD OR DELETE ROUTE / SERVICE AREA", check only the cities and counties you want to add to or delete from your
current certificate. Enter "A" to indicate selection is to be added or "D" to indicate selection should be deleted.
COUNTIES
CITIES
Alexandria Colonial Heights Fredericksburg Manassas Poquoson
Bedford Covington Galax Manassas Park
Portsmouth
Bristol Danville Hampton Martinsville
Radford
Buena Vista Emporia Harrisonburg Newport News Richmond
Charlottesville Fairfax Hopewell Norfolk Roanoke
Chesapeake Falls Church Lexington Norton Salem
Clifton Forge Franklin Lynchburg Petersburg South Boston
Accomack Caroline Franklin
King George
Nottoway
Albemarle Carroll Frederick King William Orange
Alleghany Charles City Giles Lancaster Page
Amelia Charlotte Gloucester Lee Patrick
Amherst Chesterfield Goochland Loudoun Pittsylvania
Appomattox Clarke Grayson Louisa Powhatan
Arlington Craig Greene Lunenburg Prince Edward
Augusta Culpeper Greensville Madison Prince George
Bath Cumberland Halifax Mathews Prince William
Bedford Dickenson Hanover Mecklenburg Pulaski
Bland Dinwiddie Henrico Middlesex Rappahannock
Botetourt Essex Henry Montgomery Richmond
Brunswick Fairfax Highland Nelson Roanoke
Buchanan Fauquier Isle of Wight New Kent Rockbridge
Buckingham Floyd James City Northampton Rockingham
Campbell Fluvanna King and Queen Northumberland Russell
Staunton
Suffolk
Virginia Beach
Waynesboro
Scott
Shenandoah
Smyth
Southampton
Spotsylvania
Stafford
Surry
Sussex
Tazewell
Warren
Washington
Westmoreland
Wise
Wythe
York
Williamsburg
Winchester
8. REMOVE LIMITATION / RESTRICTION INFORMATION
Complete for APPLICATION TYPE REMOVE LIMITATION / RESTRICTION
For application type "REMOVE LIMITATION / RESTRICTION", enter limitation or restriction information to remove.
9. CERTIFICATION
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.
DATE (mm/dd/yyyy)APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE
APPLICANT OR AUTHORIZED REPRESENTATIVE TITLEAPPLICANT OR AUTHORIZED REPRESENTATIVE NAME
Ä
STOP
AVOID DELAYS in processing your application, review instructions to ensure you have completed this application correctly.
10. PAYMENT METHODS
Applicants that have APPLICATION TYPES "Original Application" or "Transfer / Sale" 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.
(Check one:)
CREDIT CARD / E-Check -- provide contact number →
CHECK / MONEY ORDER -- Made payable to DMV
TELEPHONE NUMBER
NOTE: In our continuing effort to safeguard customer information, DMV does not accept credit card payments by mail or email. You may pay with a credit card
by having a Motor Carrier Services Representative contact you. We accept checks and money orders via mail.
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APPLICATION FOR COMMON CARRIERS OF PASSENGERS INSTRUCTIONS AND (Virginia Department of Motor Vehicles)

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