Check all that apply:
SECTION 1 — AUTHORITY INFORMATION
Employee Hauler
Common Carrier-Irregular Route
Common Carrier-Regular Route
Contract Passenger
Taxicab
Household Goods
Property Carrier
SightseeingBroker of Passenger
Non-Emergency Medical Transportation Carrier
Nonprofit / Tax Exempt Passenger Carrier
Write the number of each certificate, license, and permit you are applying to renew. Attach a separate page if needed.
BUSINESS STREET ADDRESS (do not give P.O. Box)
CITY
ZIP CODESTATE
FEDERAL TAX IDENTIFICATION NUMBER/SSNBUSINESS NAME (For individual applicants, give your full legal name)
SECTION 2 — 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
SECTION 3 — OTHER CARRIER INFORMATION
IFTA LICENSE NUMBER (if applicable) BASE STATE
IRP ACCOUNT NUMBER (if applicable)
BASE STATE
FMCSA MC NUMBER (Federal Motor Carrier) (if applicable) DOT NUMBER (if applicable)
SECTION 4 — BUSINESS ENTITY INFORMATION
4A. BUSINESS ENTITY TYPE (check one)
OTHERCORPORATION PARTNERSHIP (Complete Section 4B below) INDIVIDUAL
FULL LEGAL NAME SOCIAL SECURITY NUMBER
4B. PARTNERSHIP INFORMATION (enter the following information for all partners)
SECTION 5 — CERTIFICATION
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 this certification and affirmation 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, license or permit 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
FOR-HIRE INTRASTATE OPERATING AUTHORITY
CERTIFICATE, LICENSE, OR PERMIT
RENEWAL APPLICATION
OA 144M (01/01/2018)
PURPOSE: Motor carriers use this form to renew their Intrastate Operating Authority Certificate, License and/or Permit(s) and provide
business operations information.
INSTRUCTIONS: Complete all sections. Unsigned applications cannot be processed. For-hire certificates/licenses can be denied, revoked or
suspended due to certain circumstances. Refer to www.dmvNow.com for specific denial/revocation/suspension reasons.
