application for approval of transfer or lease of certificate or permit

Kentucky Transportation CabinetDivision of Motor CarriersSale, Lease, or Other TransferKentucky Intrastate Motor Carrier Authority ApplicationTC 95-5989/2013Page 1 of 2PLEASE READ AND FOLLOW INSTRUCTIONS CAREFULLY.To:ATTACH $25.00 FILING FEE MADE PAYABLE TO "KENTUCKY STATE TREASURER."Check or Money OrderKentucky Transportation CabinetOffice of Legal Services200 Mero Street, 6th FloorFrankfort, Kentucky 40622(502) 564-1257 (Motor Carriers)DOCKET NO.(Department Use Only)ALL FIELDS REQUIREDApplicant TransfereeLegal nameDoing business asStreet addressCity County State ZIPPhoneFaxEmail address (required)Mailing address (if different from above)Applicant TransferorLegal nameStreet addressCity County State ZIPPhoneFaxEmail address (required)Mailing address (if different from above)Existing qualified certificate or permit (only one per application) to be transferred or partially transferred:Is this an application for a partial transfer of the certificate or permit listed above?NoYes (If yes, enter the number of authorized vehicles to be transferred.):

Kentucky Transportation CabinetDivision of Motor CarriersSale, Lease, or Other TransferKentucky Intrastate Motor Carrier Authority ApplicationTC 95-5989/2013Page 2 of 2The applicant transferee hereby certifies that:1. The applicant transferee has attached the executed agreement (bilateral contract) detailing the terms of the proposed transferincluding any consideration paid.2. The applicant transferee is a sole proprietor?NoYes (If yes, attach the TC 95-615, Assumed Name Registration, form recorded at the County Clerk.)3. The applicant transferee is a corporation, partnership, LLC, or other registered business organization?NoYes (If yes, attach a Certificate of Existence (Domestic) or a Certificate of Authorization (Foreign) from theKentucky Secretary of State.)4. The applicant transferee has the approved indemnifying bond or commercial insurance policy required by KRS 281.655 on filewith the Division of Motor Carriers, or the applicant shall provide approved evidence before any certificate will be issued orrenewed and before any operations are conducted.5. The applicant has completed TC 95-620, Financial Statement of Business Organization, or TC 95-621, Financial Statement ofSole Proprietor, or an equivalent notarized financial statement and has enclosed it with this application.6. The applicant transferee shall advertise its intention to apply for motor carrier authority by newspaper advertisement within seven(7) days of the date this application is filed or by electronic mail correspondence. For further information, refer to TC 95-618,Instructions and Public Notice Advertisement, and TC 95-619, Affidavit of Newspaper Publication.I, the undersigned applicant transferee or applicant transferee official, after being first duly sworn, do hereby state that theabove information is true and correct to the best of my knowledge and belief.SignaturePrint namePrint titleTHIS SIGNATURE SHALL BE NOTARIZED.STATE OFCOUNTY OFSubscribed and sworn to before me on this the day of 20 .Notary PublicMy commission expires on .Attorney for Applicant (if applicable)Signature Street address Phone (including area code)Print name Street address (line 2) Fax (including area code)Firm or company name City, State, ZIP Email address (required)