Delivery Base Application Form

DELIVERY BASE APPLICATION FORM

Applicant Name:

ENTITY TYPE

Sole Proprietorship
Partnership
Corporation
Limited Liability Company (LLC)
Other:

CONTACT INFORMATION

BASE LOCATION

Base Operating Hours: From to

OPERATIONS AND SCOPE OF WORK

WHEREAS, Applicant seeks authorization to operate a delivery base to store, maintain, and dispatch delivery vehicles and personnel in connection with delivery services; and

WHEREAS, the granting authority requires assurance that the base will comply with all applicable safety, insurance, and operational standards and that the Applicant will maintain accurate records and permit inspections as provided herein; and

WHEREAS, Applicant hereby submits this application and attests to the truth and completeness of the information provided below, and agrees to the terms, conditions, and fees set forth in this form.

FLEET, STAFFING AND SAFETY

INSURANCE AND COMPLIANCE

Policy Effective Date:   Coverage Limits:

Applicant certifies that background checks are performed on drivers and applicable staff
Applicant does not perform background checks (explain below)

ATTACHMENTS

Provide copies of the following with this application (check all included):
Certificate of Insurance
Vehicle Registration List
Driver Roster with Licenses
Detailed Safety & Loss Prevention Plan
Other documents:

PAYMENT TERMS

Application Fee Amount: $

Payment Schedule:

Late Fee: — Unpaid amounts may accrue interest and collection costs.

TERM AND TERMINATION

Term Commencement Date:

Term Expiration Date (if applicable): . Unless sooner terminated in accordance with this form, the authorization shall continue until the expiration date or until revoked.

Notice Period for Termination by Applicant: days. Applicant acknowledges that the granting authority may suspend or revoke approval for cause, including but not limited to insurance lapses, safety violations, false statements, or failure to pay fees.

CONFIDENTIALITY

Applicant acknowledges that information submitted in connection with this application may be maintained by the granting authority and may be disclosed as required by law. Applicant agrees that any information expressly designated in writing as confidential and accompanied by a specific legal basis for confidentiality will be handled in accordance with applicable law. Applicant further agrees not to disclose third-party confidential information obtained as a result of operations at the base and to use commercially reasonable measures to protect such information.

GOVERNING LAW

This Application and any authorization issued in connection with it shall be governed by and construed in accordance with the laws of the State of , without regard to its conflicts of law principles.

ENTIRE AGREEMENT

This Application, together with any terms, conditions, schedules, and attachments expressly incorporated herein, constitutes the entire agreement between Applicant and the granting authority concerning the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral. Any amendments must be in writing and signed by an authorized representative of Applicant and the granting authority.

CERTIFICATION

By signing below, Applicant certifies under penalty of perjury that all information provided in this Application is true, complete, and accurate to the best of Applicant's knowledge. Applicant authorizes reasonable inspections of the proposed base, verification of insurance and registrations, and background checks of personnel as required by the granting authority.

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