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Address City State Zip Code IRP Account Number Fleet Number License Year Address Change Jurisdictional Use Contact Person Name Telephone Number Fax Number E-Mail I declare, with my signature on my registration application, that I am knowledgeable of the Federal or State Motor Carrier and Hazardous Materials Safety Regulations. The undersigned, under oath, swears under penalty of perjury that the information furnished in this application and the attached schedules are true and correct.

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