Authority: IC 8-2.1-18-6
Affected: IC 8-2.1-18
Sec. 21.
APPLICATIONS FOR SPECIAL PERMISSION.
___________________________________
(Address)
___________________________________
(Date)
Application No. _____
To The Public Service Commission of Indiana Indianapolis, Indiana 46204
___________ , by __________________________ for and on behalf (Name of Carrier) (Name of officer, specifying title)
of all carriers parties to its Tariff P.S.C.I. No. _____ , does hereby petition the Public Service Commission that he (it) be permitted, under Section 17 of the Motor Carrier Act, and as amended, to put in force the following tariff provisions to become effective _____ days after the filing thereof with the Public Service Commission:
(Here show matter as directed by paragraph (e)(1) of this rule [this section].)
Your petitioner further represents that the said: (state whether rates, charges, classification ratings, or other provisions) above mentioned will be published in (here show matter as directed by paragraph (e)(2) of this rule [this section]). (Here state matter as directed by paragraph (e)(3) of this rule [this section].) (Here state matter as directed by paragraph (e)(4) of this rule [this section].) (Here state fully matter as directed by paragraph (e)(5) of this rule [this section].) (Here show justification as directed by paragraph (e)(6) of this rule [this section].)
_____________________________
(Name of carrier)
By _____________________________
(Name and title) Verification:*
The above statement was subscribed and sworn to before me this _____ day of _____ , 19 _____ .
____________________________
(Notary Public) When the publication is made by an agent, appropriate change should be made in the introductory and closing paragraphs of this form.
* Only the original need be executed.
45 IAC 16-3-21
Transferred from the Indiana Utility Regulatory Commission ( 170 IAC 2-3-21) to the Department of State Revenue ( 45 IAC 16-3-21) by P.L. 72-1988, SECTION 12, effective July 1, 1988.