MC078 (12-2012)
POWER OF ATTORNEY (POA)
Registration / Tax Year: 20_________
Please Note:
You must complete this form if anyone other than yourself will be acting on your behalf
Motor Carrier Account Number: FEIN:
Full Legal Name:
Doing Business As:
Address:
Telephone (________) _________-_____________ Fax (________) __________-_____________
The following agent is authorized to provide and receive information and to perform any and all acts that I can
perform as the registrant/taxpayer with respect to any Nevada Motor Carrier Division matters.
I would like all correspondence to be sent to:
Registrant/Taxpayer: _ Authorized Agent: _ Both __ _
Authorized Agent:
Address:
Telephone (________) _________-_____________ Fax (________) __________-_____________
This Power of Attorney authorizes the above named agent to:
1. Sign and file all registration documents, special fuel, and motor fuel documents and tax forms.
2. Provide, receive, and discuss information regarding the above account.
Please Note: The carrier is responsible for notifying the Department when this POA is no longer valid.
I hereby certify the Nevada Department of Motor Vehicles, Motor Carrier Division is authorized to release to the
above named authorized agent any and all information in their files with respect to any matters regarding the
above account. I relieve the Department and their representatives of any liability related to the release of such
information to the above named authorized agent. I understand this authorization does not absolve me, as the
registrant/taxpayer, of the responsibility to ensure that all tax returns, taxes, and registration payments are filed
and paid on time. Also, I understand this authorization replaces any prior authorization filed with the Department.
Signatures must be original. Photocopies are not acceptable.
___________________________________________________________________________
Authorized Registrant/Taxpayer signature (Required) Date (Required)
___________________________________________________________________________
Printed Full Legal name and title (Required) Date (Required)
___________________________________________________________________________
Signature of Notary or Authorized DMV Representative (Required) Date (Required)
555 WRIGHT WAY
CARSON CITY, NV 89711-0600
(775) 684-4711
fax (775) 684-4619
http://www.dmvnv.com/mchome.html
