green operator retrofit application

Section 1 of 5

Please list which Port of Virginia facilities you serve.Company NameRegistered OwnerAuthorized RepresentativeEIN (Employer ID Number)ICC NumberTWIC Card NumberType of BusinessNumber of Employees (Independent Owner Operator will most likely be 1)Name of Truck Driver (if other than Owner)Registered Owner’s Street AddressCity/State/ZipTelephoneFaxEmail

Section 1 of 5 complete. Go to Vehicle Info Tab

Section 2 of 5

Truck Information

Truck MakeTruck YearNumber of AxlesTruck License Plate Number

Truck ModelGVWR (Lbs.)Vehicle ID Number (VIN)Licensing State

Engine Information

Engine MakeEngine ModelFuel Type (Diesel, CNG, LNG, etc.):

Engine Model YearHorsepower

Operational Information

Does Your Odometer Work?YesNoDate of Odometer Reading# Years Truck Owned.
*You must have owned the truck for at least 1 year, according to the date on your title, to be eligible.Is your truck currently in operation or is it sitting?Title NumberOver the past two years, what is the average number of trips made (per week) to The Port of Virginia facilities? What do you typically haul (check all that apply)?

Lien information

This vehicle being replaced is free and clear of all liensYesNo

(If you answered “No”, you agree to pay off all indebtedness, receive lien releases and deliver a clear certificate of title free of any and all liens as a condition to delivery of your old truck for scrappage and receipt of grant funds for a replacement truck.)

Current Odometer ReadingPlace a check here if this reading is an estimate. Place a check here if this odometer has rolled over Number of times Odometer has rolledAnnual Miles (January 1, 2014 – December 31, 2014)What is the average number of hours (per day) that your truck spends idling (engine running but truck not moving)?Over the past two years, what is the average number of days (per week) that you have driven this truck for work? Has the truck been used to transport cargo to and from The Port of Virginia facilities on a regular basis for the last two years?YesNo

Section 2 of 5 complete. Go to Obligations Tab

Section 3 of 5

I do hereby certify the following (Please read and initial next to each item):

1. That I have reviewed and understand the application, including this Notice of Obligations, and that all of the information I have submitted is true and correct.2.That I will not submit any other applications for funding of this same truck(s) under this program. 3.That Program funds were not used to previously upgrade the equipment identified in this application. 4. That I will make the old truck available for pre-award inspections and make the truck available for inspection after the award is made. 5. That neither the truck owner nor the truck has any outstanding violations of The Port of Virginia facility regulations. 6. That I have already paid or otherwise settled all outstanding violations against the old truck. (Applicants with outstanding violations at the time of the application will be ineligible for funding during the current round of solicitations but may reapply in subsequent solicitation periods)

Section 3 of 5 complete. Go to Company Commitment Tab

Section 4 of 5

NameTitleDate

By clicking submit you certify that you are the authorized representative of the company applying for the funding and that the information provided herein is true, accurate and complete to the best of your knowledge and belief.

Section 4 of 5 complete. Go to Required Documents Tab

Section 5 of 5

To complete your application please click submit below AND email the following documents to Susan Stephenson at sstephenson@ecologixgroup.com. Once we have received your application you will be sent a confirmation email within one business day.

A copy of a valid ID card from The Port of Virginia (front and back).
A copy of a valid TWIC card (front and back).
A copy of the Virginia vehicle title or other state title and registration or similar state title and registration if registered in another state for the vehicle(s) to be replaced.
Proof of insurance for the truck to be retrofitted.
Photograph of truck to be retrofitted with license plate clearly visible.

Section 5 of 5 complete.