Chp296_0419.pdf
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STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
APPLICATION FOR SCHOOL BUS CONTRACTOR'S LICENSE
CHP 296 (Rev. 4-12) OPI 062
Please print or type
REASON FOR APPLICATION
Initial license ($100.00)
New license – majority change in
ownership or control ($100.00)
Renewal ($75.00)
Late renewal ($100.00)
Duplicate-license lost or destroyed
($5.00)
Replacement – correction or
change of name and/or address
only (no fee, attach current license)
Amended – minority change in
ownership or control (no fee)
APPLICANT NAME (COMPANY NAME) FEDERAL EMPLOYER I.D. NUMBER (EIN)
(IF NONE, LEAVE BLANK)
SOCIAL SECURITY NUMBER (SSN)
(MUST BE PROVIDED FOR INDIVIDUALS)
OWNERSHIP INFORMATION (MARK ONLY ONE)
CORPORATION LIMITED LIABILITY COMPANY (LLC) PARTNERSHIP
INDIVIDUAL - PROVIDE DRIVER'S LICENSE NUMBER AND STATE:
IF THIS IS A NAME CHANGE, ENTER PREVIOUS NAME
ADDITIONAL NAME THE COMPANY IS DOING BUSINESS AS (IF NO DBA LEAVE BLANK) MAIL LICENSE ATTENTION:
MAIN OFFICE STREET ADDRESS CITY STATE ZIP CODE
MAILING ADDRESS (If different from applicant address)
CITY STATE ZIP CODE
CALIFORNIA CORPORATION NUMBER CALIFORNIA CARRIER
IDENTIFICATION NUMBER
CHP SCHOOL BUS CONTRACTOR LICENSE NUMBER
AND EXPIRATION DATE
PUC AND/OR US DOT NUMBER(S) TOTAL SCHOOL
BUSES OPERATED
APPLICANT BACKGROUND YES NO
a. Has the applicant ever been issued a similar license by the Department of California Highway Patrol, another California state agency, or an agency of another
state or the federal government? (Other than a renewal of this license) If "yes" explain on reverse.
b. Has the applicant ever had any license denied, suspended, or revoked by the Department of California Highway Patrol, another California state agency, or an
agency of another state or the federal government? If "yes" explain on reverse.
c. Has the applicant ever been a partner, officer, director or controlling shareholder in a company or corporation whose license was denied, suspended, or
revoked by the Department of California Highway Patrol, another California state agency, or an agency of another state or federal government? If "yes"
explain on reverse.
d. Has the applicant, a partner, officer, director or controlling stockholder (if a corporation or partnership) ever been convicted of any offenses? (Traffic
violations involving fines or forfeitures of bail of $50.00 or less need not be reported) If "yes" explain on reverse.
PRINT OR TYPE NAME AND TITLE OF EACH OWNER, PARTNER, OFFICER,
DIRECTOR OR CONTROLLING SHAREHOLDER.
PRINT OR TYPE THE NAME OF EACH CALIFORNIA SCHOOL DISTRICT, INCLUDING
COUNTY, AND CONTACT NAME AND PHONE NUMBER(S) FOR WHOM YOU
PROVIDE CONTRACTED SERVICE. (USE BACK OF APPLICATION IF NECESSARY)
APPLICATION CERTIFICATION
It is agreed that the licensed activity will be conducted in compliance with all applicable laws and regulations, and that the applicant is aware of all applicable California laws
and regulations pertaining to motor carrier safety and student transportation. It is understood that violation of any law or regulation may result in the filing of a criminal action
in a court of law or the filing of an administrative action to suspend or revoke the license. It is also understood that misrepresentation of a material fact in conjunction with
this application is a misdemeanor of the California Vehicle Code and may result in denial or revocation of the license. State law allows the State Board of Equalization and
the Franchise Tax Board to share taxpayer information with the Department and requires a licensee to pay any state tax obligation, or their license may be withheld or
suspended if the state tax obligation is not paid.
AUTHORIZED CERTIFIER'S SIGNATURE PRINT OR TYPE NAME AND TITLE DATE
CHP USE ONLY
DATE AMOUNT
LICENSE NUMBER LOCATION CODE
CHECK DATE
CASHIER EXPIRATION DATE
CHECK NUMBER
ISSUE DATE
CA NUMBER CONTROL NUMBER
LICENSEE NAME AND MAILING ADDRESS
INSTRUCTIONS TO APPLICANT
MAIL THE ORIGINAL COMPLETED FORM(S) WITH REQUIRED FEE TO:
PHONE NUMBER
