Fillable CERTIFICATE OF FITNESS RENEWAL APPLICATION (Virginia Department of Motor Vehicles)

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CERTIFICATE OF FITNESS RENEWAL APPLICATION (Virginia Department of Motor Vehicles)

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OA 153 (07-01-2017)
TRANSPORTATION NETWORK COMPANY (TNC)
CERTIFICATE OF FITNESS
RENEWAL APPLICATION
PURPOSE: TNCs use this form to renew their Certificate of Fitness with DMV.
INSTRUCTIONS: Send completed form to Motor Carrier Services at the address shown above. 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) 367-1003 (fax) or
mcsonline@dmv.virginia.gov (e-mail)
BUSINESS STREET ADDRESS (do not give P.O. Box)
CITY
ZIP CODESTATE
CERTIFICATE NUMBERBUSINESS NAME (For individual applicants, give your full legal name)
BUSINESS INFORMATION
TRADE NAME OR DOING BUSINESS AS (if different from Business Name)
BUSINESS MAILING ADDRESS (if different from above)
CITY
ZIP CODESTATE
PRIMARY CONTACT PERSON NAME FAX NUMBERTELEPHONE NUMBER
PRIMARY CONTACT PERSON TITLE PRIMARY CONTACT PERSON EMAIL ADDRESS
BUSINESS ENTITY INFORMATION
BUSINESS ENTITY TYPE (check one)
OTHERCORPORATION PARTNERSHIP INDIVIDUAL
FULL LEGAL NAME SOCIAL SECURITY NUMBER
PARTNERSHIP INFORMATION (enter the following information for all partners)
CERTIFICATION
I certify that every TNC partner vehicle that will be authorized to operate on the TNC digital platform is covered by an insurance policy that
meets the requirements under Title 46.2, Chapter 20, Article 15.
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 Workers' Compensation Act of Title 65.2 and with 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 or
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
PAYMENT METHODS (Select 1 or 2)
1. Annual Renewal Fee: $60,000.00 2. Driver Transcript Surcharge
Check one:
Check - Made payable to DMV
E-Check - Contact (804) 249-5130
ACH Credit - Contact DMV's Cashier Office (804) 367-1884
$20.00 surcharge collected in addition to other applicable fees,
at the time of payment for each driver transcript.
DO NOT enclose payment with this form.
OA 153 (07-01-2017)
REASONS FOR DENIAL, SUSPENSION OR REVOCATION
1. Material misstatement or omission in application for license, certificate, permit, identification marker, or vehicle registration.
2. Failure to comply subsequent to receipt of a written warning from the Department or any willful failure to comply with a lawful order, any
provision of this chapter or any regulation promulgated by the Department under this chapter, or any term, condition, or restriction of a
license, permit, or certificate.
3. Failure to comply with zoning or other land use regulations, ordinances, or statutes.
4. Use of deceptive business acts or practices.
5. Knowingly advertising by any means any assertion, representation, or statement of fact that is untrue, misleading, or deceptive relating to
the conduct of the business for which a license, certificate, permit, identification marker, or vehicle registration is held or sought.
6. Having been found, through a judicial or administrative hearing, to have committed fraudulent or deceptive acts in connection with the
business for which a license, permit, or certificate is held or sought or any consumer-related fraud.
7. Having been convicted of any criminal act involving the business for which a license, permit, or certificate is held or sought.
8. Failure to comply with § 46.2-2056 or any regulation promulgated pursuant thereto.
9. Improper leasing, renting, lending, or otherwise allowing the improper use of a license, certificate, permit, identification marker, or vehicle
registration.
10. Having been convicted of a felony.
11. Having been convicted of any misdemeanor involving lying, cheating, stealing, or moral turpitude.
12. Failure to submit to the Department any tax, fees, dues, fines, or penalties owed to the Department.
13. Failure to furnish the Department information, documentation, or records required or requested pursuant to statute or regulation.
14. Knowingly and willfully filing any false report, account, record, or memorandum.
15. Failure to meet or maintain application certifications or requirements of public convenience and necessity, character, fitness, and financial
responsibility pursuant to this chapter.
16. Willfully altering or changing the appearance or wording of any license, permit, certificate, identification marker, license plate, or vehicle
registration.
17. Failure to provide services in accordance with license, permit, or certificate terms, limitations, conditions, or requirements.
18. Failure to maintain and keep on file with the Department motor carrier liability insurance, issued by a company licensed to do business in
the Commonwealth, or a bond, certificate of insurance, certificate of self-insurance, or unconditional letter of credit in accordance with this
chapter, with respect to each motor vehicle operated in the Commonwealth.
19. Failure to comply with the Workers' Compensation Act of Title 65.2.
20. Failure to properly register a motor vehicle under this title.
21. Failure to comply with any federal motor carrier statute, rule, or regulation.
22. Failure to comply with the requirements of the Americans with Disabilities Act or the Virginians with Disabilities Act (§ 51.5-1 et seq.).
23. Inactivity of a motor carrier as may be evidenced by the absence of a motor vehicle registered to operate under such certificate or permit
for a period of greater than three months.
24. Failure to comply with any provision regarding the filing and registered agent requirements set forth in Title 13.1.
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CERTIFICATE OF FITNESS RENEWAL APPLICATION (Virginia Department of Motor Vehicles)

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Completed 2 November 2020

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