green operator replacement application

Section 1 of 5

Please list The Port of Virginia facilities you serve. Company NameRegistered OwnerEIN (Employer ID Number)ICC /DOT/MC NumberTWIC Card NumberType of BusinessName of company you are leased to (if owner-operator)Is your business classified and registered as a Minority Owned or Women Owned Small
Business?Number of Employees (Independent Owner Operator will most likely be 1)Driver’s License # (of Owner Operator or Truck Driver)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 ModelSerial NumberFuel Type (Diesel, CNG, LNG, etc.):

Engine Model YearHorsepowerEngine Family NumberIs this the original engine from the truck?

Operational Information

Does Your Odometer Work?YesNoDate of Odometer Reading# Years Truck Owned.
*You must have owned the truck for at least 2 year, according to the date on your title, to be eligible.Is your truck currently in operable or is it sitting?If sitting, why?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 rolledMiles (The vehicle must have logged at least 7,000miles per year for the 2-year period immediately prior to the application date)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 check 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 I will make the old truck available for pre-award inspections and destruction and make the new truck available for inspection after the award is made. 4. That neither the truck owner nor the truck has any outstanding violations of The Port of Virginia regulations. 5. 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)6. That I will use the new truck purchased to service Port of Virginia facilities for two (2) years after taking possession of the new vehicle.7. That I will apply a Green Operator decal on my new truck purchased with program funds for a period of 2 years after purchase. Program provides the decals.

Section 3 of 5 complete. Go to Company Commitment Tab

Section 4 of 5

NameTitleDate

By clicking submit I hereby certify under penalty of perjury from my personal knowledge both that I am the lawful owner of the vehicle(s) identified in this application applying for the funding, and that all information provided in this application is true, accurate and complete.

Investing Public Funds / Maintaining Public Trust
Intentional falsification of information provided by an applicant with the specific intent to avoid meeting any aspect of the program’s requirements may lead to the individual being prosecuted to the extent allowed under law and may be used as
an adverse factor in regards to future applications for rebate awards.

The Virginia Port Authority is committed to the integrity of the program and encourages reporting of any known concerns involving any aspect of the program especially related to suspected fraudulent activity. Visit https://www.oig.dot.gov/hotline
for more information on suspected fraud.

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 Ed Mihalski at emihalski@ecologixgroup.com. Once we have received your application you will be sent a confirmation email within one business day.

Provide a copy of a valid TWIC card (front and back) as well as a PRO-PASS report going back a minimum of 6 months.
Provide a copy of the Department of Motor Vehicles title AND a valid registration for the vehicle(s) to be replaced.
Provide proof of valid insurance for the truck to be replaced.
Provide photographs of truck to be replaced with license plate clearly visible.
Provide a video showing the truck is operable and a photo of the engine tag/serial number.
Provide letter of preapproval for financing.

Section 5 of 5 complete.

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Section 1 of 5

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)

Engine Information

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

Engine Model YearHorsepowerEngine Family Number

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 or Richmond? What do you typically haul (check all that apply)?

Lien information

This vehicle being replaced is free and clear of all liensYesNo

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 or Richmond 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 destruction and make the new truck available for inspection after the award is made. 5. That neither the truck owner nor the truck has any outstanding violations of Ports of Virginia and Richmond 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 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 (both primary liability/cargo and non-trucking liability/bobtail insurance) for the truck to be replaced.
Photograph of truck to be replaced with license plate clearly visible.
A letter showing you have been pre-approved for a loan to cover the remaining cost of the new truck.

Section 5 of 5 complete.

Thank you! Your submission has been received!

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