Fillable Tnc Application Packet (City of Duluth)

Fill Online, Printable, Fillable, Blank Tnc Application Packet (City of Duluth) Form

Use Fill to complete blank online CITY OF DULUTH (MN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Tnc Application Packet (City of Duluth)

On average this form takes 5 minutes to complete

The Tnc Application Packet (City of Duluth) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Duluth

BROWSE CITY OF DULUTH (MN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
City of Duluth – City Clerk’s Office
411 W First Street – City Hall 330
Duluth, MN 55802-1189
Phone: (218) 730-5500
Fax: (218) 730-5923
For Office Use Only
Date:
License
No._
TRANSPORTATION NETWORK COMPANY
LICENSE APPLICATION
GOVERNMENT DATA PRACTICES ACT - CLASSIFICATION WARNING: The data you supply on this form will be used to
process the license you are applying for. You are not legally required to provide this data, but we will not be able to
process the license without it. Some of the data will be classified as public data if and when the license is granted.
Private financial information including a tax identification number and social security number are classified as private
data and will be available to governmental personnel and other governmental agencies whose access is necessary to
perform their official duties.
TRANSPORTATION NETWORK COMPANY (“TNC”) FEE = $3597.00
TOTAL $_
LICENSEE BUSINESS NAME & ADDRESS, PHONE AND EMAIL ADDRESS
(Individual, Partnership, Corporation, LLC)
EMAIL
A
DDR
ESS:
B
UISN
ESS
PHON
E
NO:
CONTACT/AGENT NAME[s] & ADDRESS[ES]: CONTACT/AGENT PHONE & EMAIL ADDRESS
EMAIL
A
DDRESS
B
USIN
ESS
PHON
E
N
UMBER
LICENSEE HEREBY SWEARS AND ATTESTS THAT ALL INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT TO
THE BEST OF ITS KNOWLEDGE AND THAT LICENSEE SHALL COMPLY WITH ALL PROVISIONS GOVERNING ITS
OPERATION SET FORTH IN CHAPTER 47 OF DULUTH CITY CODE, ALONG WITH ALL OTHER APPLICABLE
PROVISIONS OF LOCAL, STATE OR FEDERAL LAW, AS MAY BE AMENDED.
BY
:
LICEN
SEE OR ITS DULY AUTHORIZED AGENT OR REPRESENTATIVE
On this day of _, 2_ , before me, a Notary Public within
and for said County and State, personally appeared _, to me
well known to be the person named in and who executed the foregoing instrument, and
acknowledged that they executed said instrument as their free act and deed, for the uses and
purposes therein expressed.
NOTARY PUBLIC
My Commission Expires:
CITY OF DULUTH
CITY CLERK'S OFFICE
330 City Hall
!
411 West First Street
Duluth, Minnesota 55802-1189
URL: www.duluthmn.gov
Phone (218) 730-5500
Fax (218) 730-5923
TRANSPORTATION NETWORK COMPANY LICENSE
APPLICATION SPECIFICS/REQUIRED DOCUMENTATION
All of the following items must be submitted before an application is deemed complete for
consideration.
1.
License
Fee Payment (annual fee, no prorating) $ 3,597.00
2. Certificate of Compliance/Exemption - Minnesota Workers’ Compliance Law form.
3
. Corporate Documentation
If
incorporated
or a partnership please
provide:
•
Copy of your company's Certificate of Incorporation from the Minnesota
S
e
c
r
e
t
a
r
y of
State
(SOS)
or proof of current registration with the
SOS
demonstrating you have legal
authorization to operate within
Minnesota;
•
Signed statement listing the owners of the corporation (including the percentage of
ownership held by each
individual).
4. Photo of
Distinctive
Trade Dress
Trade dress must be readable during daylight hours at a distance of at least 50 feet,
reflective,
illuminated
or otherwise patently visible so as to be seen in darkness, and
s
uitab
le
fo
r
identifying
that a particular vehicle is endorsed
b
y, and affiliated with, a particular licensee.
5. TNC policies for (a) non-discrimination and driver notice under Section 47-56; (b) zero
tolerance for drug and alcohol abuse under Section 47-61; and (c) evaluating and investigating
negative feedback received about the condition of a vehicle under Section 47-52(a).
6.
Insurance
Certification in accordance with Minn. Stat. §
65B.472.
The TNC must file insurance documentation (i.e., certificate of insurance, policy binder,
etc.)
evidencing compliance with the coverage limits provided under Minn. Stat. § 65B.472, as may be
amended.
7. Form appointing TNC Agent/Power of Attorney for official notices and service of legal
process.
8. Tax Identification Form required under Minn. Stat. § 270C.72, subd. 4, as may be amended
(attached)
9. If different from the agent identified under No. 7 above, TNC preferred contact information for
any and all designated TNC representatives and agents - including name, business email,
address, and phone number – for receipt of city communications relating to (a) legal process
and official notices under Sections 47-51 and 47-67; (b) service-related investigations and
complaints pursuant to Sections 47-51 and 47-68; (c) police investigations and/or vehicle
inspection matters; and (d) records requests pursuant to Section 47-66.
TNC AGENT FOR NOTICES/SERVICE OF PROCESS/POWER OF ATTORNEY
KNOW ALL BY THESE PRESENTS, that I, _______________________________________,
( Name of Licensee and/or Its Duly Authorized Representative or Agent),
having applied for a license to operate a Transportation Network Company (“TNC”) within the
City of Duluth, do hereby make, constitute and appoint:
TNC AGENT NAME & BUSINESS ADDRESS: TNC AGENT PHONE & EMAIL ADDRESS
_____________________________________ EMAIL ADDRESS____________________________________
_____________________________________ BUSINESS PHONE NUMBER __________________________
_____________________________________
and his/her successor in office, my true and lawful ATTORNEY, on whom all notices, summonses
and all legal processes in any action or legal proceeding against me, arising from or on account
of the operation of said Transportation Network Company within the City of Duluth, may be served.
Said Attorney is hereby duly authorized and empowered, as my agent, to receive and accept
service of all notices, summonses and all legal processes in any action or legal proceeding against
me as aforesaid, as provided by the laws of the State of Minnesota, and such service shall be
deemed valid personal service upon me, said ______________________________________.
(Name of Licensee)
This appointment is to continue in force irrevocably so long as any such TNC is operated under
the above-mentioned permit, and so long as any liability arising from or on account of said
operation of such TNC remains outstanding.
IN TESTIMONY WHEREOF, I have hereunto set my hand and seal at the City of Duluth,
Minnesota, this ______day of __________________________, 2___.
_______________________________________________
(Signature of Applicant/Licensee)
STATE OF MINNESOTA )
) ss:
COUNTY OF ST. LOUIS )
On this ________day of _______________________, 2____, before me, a Notary Public within and for said County
and State, personally appeared ______________________________, to me well known to be the person named in
and who executed the foregoing instrument, and acknowledged that they executed said instrument as their free act and
deed, for the uses and purposes therein expressed.
_________________________________________________
NOTARY PUBLIC
My Commission Expires: ___________________
City of Duluth
TNC Vehicle Inspection Report
Vehicle Owner Name
Vehicle Year Make VIN (last 6 digits) License Plate Odometer
F = FAIL/ OUT OF SERVICE P = PASS
1. BELTS, HOSES, LUBRICANTS
F
P
7. STEERING
F
P
11. BODY
F
BELT
P/S
AIR PUMP
ALT
A/C
STEERING LINKAGES /COMPONENTS
PAINT COLOR, DENTS, DINGS, RUST
BALL JOINTS
WINDSHIELD
HOSE
CRACK
SOFT
HEATER
RAD
PINION SEALS
DOORS-AT LEAST 5 INCLUDING TRUNK
TIRE WEAR LF RF LR RR
DOOR HANDLES LF RF LR RR
PULLEYS & WATER PUMP
TIRE WEAR/RIM CONDITION
DOOR WINDOW LF RF LR RR
RADIATOR & PRESSURE CAP
WHEEL ALIGNMENT- TEST/VISUAL
FENDERS – FRONT
COOLANT: LEVEL COND
PS PUMP AND LEAKS
QUARTER PANELS - REAR
TRANS FLUID LEVEL COND
8. INSTRUMENTS
F
P
MIRRORS LF INTERIOR RF
ENGINE OIL: LEVEL COND
OIL PRESSURE
BUMPER COVERS
PWR STR FLUID LEVEL
ENGINE TEMP
DECAL/COMPANY MARKING
BATTERY POSTS & CABLES
CHARGING SYSTEM
2. POLLUTION CTRL/FUEL SYS
F
P
SPEEDOMETER
GLASS
FUEL LEADS (VISUAL)
ODOMETER
GENERAL BODY CONDITION
GAS TANK
HEATER/DEFROSTER
12. GENERAL
F
GAS GAUGE
AIR CONDITIONING
HORN
IDLE
NORMAL:
SRS AIRBAGS
AIR CONDITIONER
3. ENGINE/POWER ANALYSIS
F P
FAN SPEED
TEST
DRIVE
ENGINE PERFORMANCE
WS WIPERS/WASHER
ENGINE NOISES
HEADLIGHTS
NORMAL ACCELERATION
FOCUS/CANDLE POWER
HI LOW PARKING
ENGINE MOUNTS
RIGHT TURN LIGHTS
OIL LEAKS
LEFT TURN LIGHTS
4. TRANSMISSION
F
P
9. BRAKING SYSTEM
F
P
BRAKE LIGHTS
TEST
DRIVE
NORMAL TRAN OPERATION
FLUID LEVEL
13. TRUNK
F
SPEEDOMETER OPERATION
PEDAL RESERVE
SPARE TIRE N/A
GEAR SHIFT INDICATOR
BRAKE HOSES & LINES
TRUNK UPHOLSTERY CONDITION
5. DRIVE TRAIN
F
P
MASTER CYLINDER/ABS
LATCH OPENS CLOSES
TEST
DRIVE
DRIVE LINE:
PARKING BRAKE
FUEL LEAKS/SMELLS
NOISE
REMAINING LINING/PAD
14. INTERIOR
F
VIBRATION
FRONT REAR
DRIVER/PASSENGER INTERIOR
WHEEL CYLINDERS/CALIPERS
UNCLEAN/DIRTY/SOIL/ODORS
DRUM/DISC CONDITION
FRONT SEAT # REAR SEAT #
10. SUSPENSION/FRAME
F
P
CONDITION:
6. EXHAUST SYSTEM
F
P
FRAME/ENERGY ABSORB BUMPER
DASHBOARD
CATALYTIC CONVERTER
FRAME/CROSS BARS
HEADLINER
EXHAUST PIPE/TAIL PIPE
STABILIZER BAR & LINKS
SEATBELTS (FRONT/REAR)
MUFFLER
STRUT/SHOCKS LF RF LR RR
FLOORS
HANGER/CLAMPS
SPRINGS/BRUSHINGS
Comments:
Type of Inspection:
INITIAL ANNUAL
Facility Name:
Address:
Telephone:
Date of Inspection
Inspection Results
Pass Fail
Technician Name (print)
Technician Signature
Employee #
Date of Inspection
Reinspection Results
Pass Fail
Technician Name (print)
Technician Signature
Employee #
June 2015
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Tnc Application Packet (City of Duluth)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document